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The Journal of inebriety

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INEBRIETY

Published under the Auspices of The American Association
for the Study and Cure of Inebriates .

T. D. CKOTHERS, M.D., Editor,
Hartford, Conn.

$2.00 Per Year.

Vol. XVIII, 1896.

HARTFORD, CONN.:

The Case, Lockwood & Brainard Company, Printers.

EUROPEAN AGENCY: Bailueiiei, Tindall a Cox,
ao King William Street, on the Strand, London, W. C.

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• •• •

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203638

INDEX, VOL. XVIII.

PAGE.

Alcohol Insanity, ...... i

Andriesen, Dr. W. Lloyde, . . . . . i

Angina Pectoris due to Alcohol, . . . *43

Alcoholic Poisoning and Strychnine, . . » . 66

Alcohol on the Central Nervous System, . . .109

Alcoholic Neuritis and Tuberculosis, . . .129

Alcoholic Inebriety, . . . . .223

Alcoholic Cirrhosis of the Liver, . . . .301

Alcoholic Neuritis in Old Age, .... 301

Alden, Dr. C. H., ...... 363

Ball, Dr. M. O., ; . . . . .67

Berkley, Dr. Henry J., . . . . .109

Bromides, effects of, . . . . . .252

Crothers, Dr. T. D., 51, 82, 86, 139, 180, 189, 196,281, 292,

354 , 394 , 402

Cocaine Poisoning, . . . . . . 67

Cocaine, its use and Accidents, . . . 209, 309

Cannabinomia, ...... 265

Constipation in cases of Tea-poisoning and Inebriety, . 383

Chloride of Sodium Inebriety, .... 389

Delirium Tremens Treatment, . . . . 27

Day, Dr. Albert, Sketch of, . . . . • 5 1

Delirium Tremens as seen in the eye, . . . 165

Dipsomania in Insanity, . . . .173

Index .

PACK.

Davis, Dr. A. E., . . . . .165

Delusions in Inebriates, . . . .189

Dalrymple Home in England, .... 263

Danger from the use of Alcohol in Schools, . . 290

Dipsomania as a Defense for Crime, . . . . 320

Delbose, Dr. E., ..... 309

Effect of Acute Alcohol Poisoning, .... 338

Hypnotism in the Management of Inebriety, . .139

Habitual Offenders in Scotland, .... 138

Heredity Case, . . . . 197

Hydrocynate of Iron, . . . . .202

Habitual Drunkards in Austria, .... 248

Hygienic Treatment of Dypsomania, . . 273

Homes for Inebriates’ Association, .... 304

Hereditary Inebriety, ..... 390

Inebriety and Insurance, . . . . . 78

Inebriety, Clinical Study of, . . . .82

Inebriety, Moral Insanity of, . . . .84

Intemperance and Mental Disease, . . . .119

Inebriety, Conditions which precede it, . . 180

Inebriate of Sound Mind, can he be ? . . .190

Inebriety in Infancy, . . . . .192

Inebriety and Language Symptom, . . . .194

Intoxicated or Dying, . . . . .198

Island Inebriate Home, . . . .272

Inebriety and Homicide, . . . .281

Inebriety and Sobriety in Royal Circles, . . . 293

Inebriety among Railroad men, .... 304

Intoxication and Insanity, ..... 330

Inebriety a Defense for Crime, .... 385

Intoxicated Wasps, ...... 388

Inebriety in the Adirondacks, .... 398

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Index .

PAGB.

Journal for 1896, . . . <

. . 82

Kerr, Dr. Norman, .

. 27

Kinney, Dr. E. Spencer,

56, 223, 349

Kiernan, Dr. James G.,

. 3 2 °

Lunacy and Inebriety,

. 179

Marks, Dr. Heine,

. 145

Morphinism, Treatment of, .

. 174

Morphinism in Children,

. . 200

Morphine Habit,

. 234

Mitchell, Dr. S. Wier,

• 255

Mental Impairment in Children,

• 275

Medical Treatment of Inebriety,

• 354

Ophthalmoscopic appearance of the Eye in Delirium Tre¬

mens, ....... 165

Obstacles to the Successful Treatment of Alcoholic Inebriates, 349

Phelps, Dr. R. M., . . . . . .73

Pierce, Dr. Bedford, . . . . . . .119

Precocity in Childhood followed by Inebriety, . . 288

Personal Experiences, ..... 297

Psychical Periodical Inebriates, .... 396

Paretic States in Inebriety, ..... 400

Report of Massachusetts Hospital for Dipsomaniacs, . 35

Report of Walnut Lodge Hospital, . . . .44

Report of One hundred and Twenty-Five Cases, . -73

Report on the Liquor Traffic in Canada, . . .176

Relations of Alcoholic Indulgence to Insanity, . 376

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Index.

I'AGB.

Strychnine and Alcohol Poisoning,.. .. . .66

Symptom of Language in Inebriety, . . . . 194

Statistics of Tobacco and Tea, . . . 301

Searcey, Dr. J. T., ....... 330

Treatment of Delirium Tremens, . . . 27

Trance, Double Consciousness, . . . . 56

Trional, Reports of, . . . . . 87

Tuberculosis and Alcoholic Neuritis, . . .129

Treatment of Alcohol Morphine and Cocaine Cases, . 145

Treatment of Morphinism, ..... 174

Tobaccoism, . . . . . . .181

Treatment of Consumption, ..... 222

Treating Female Inebriates, ..... 259

Tetanus following Morphine Injections, . . . 267

Toxaemia from Tobacco and Alcohol, . . . 266

Tea on the Digestive Organs, . . . .271

Two Theories, . . . . . . 283

Treatment of Relatives of Inebriates, . . . 285

Treatment of Inebriety by Newspapers, . . . 287

Treatment of Alcoholism, ... . . 363

Use of Cocaine, and Accidents resulting from it, . . 309

Walker, Dr. H. F.,.234

Wyman, Dr. H. M., ...... 273

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ALBERT DAY, M.D.

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THE

Quarterly Journal of Inebriety.

Subscription, $2.00 per year.

Vol. XVIII. JANUARY, 1896. No. 1.

This Journal will not be responsible for the opinions of contributors, unless
indorsed by the Association.

ALCOHOL INSANITY, IN THE LIGHT OF MOD¬
ERN PATHOLOGY.

By W. Lloyd Andriezen, M.D.,

Pathologist and Assistant Medical Officer West Riding Asylum , England .

While in the majority of cases the onset and early history
of mental disorganization under alcohol point to extensive
and wide-spread involvement of brain areas, it happens that
in a certain number of others, these extensive and general¬
ized changes are by no means the most prominent or typical
feature, the change in these being more intensive and spe¬
cialized, falling with peculiar vehemence on this or that sen¬
sorial, psychical, or psychomotor region, and comparable,
therefore, to other local and intensive lesions like the focal
epilepsies. It is, we think, in the latter type of alcoholic
insanity we find the features which tie this class to the in¬
stinctive criminaloid and the epileptic individuals in whom
the typical and peculiar morbid characteristics are also inten¬
sive apd specialized. We have seen how, in the Jacksonian
epilepsies, the primary focus of disease may be in some area
of the psycho-motor, sensorial, or psychical sphere, and that
the external manifestations vary accordingly.

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Alcohol Insanity.

So it is with our early alcholic insanities. It may happen
in some that the whole progress of the brain (mental) disease
will have progressed in an extensive and generalized fashion,
gradually lapsing into chronic weakmindedness and terminal
dementia. During the period of lapsing into such dementia,
or later, when the dementia is obvious, it will happen that
these patients exhibit the most protean and multiform clin¬
ical symptoms — e. g. t senile excitement, emotionalism, epi¬
leptiform convulsions, cerebral softenings and paresis, apo¬
plexies, acute hallucinatory excitement, etc., etc.; a vast sea of
symptoms in which the flotsam and jetsam of the most varied
psychical and bodily conditions are present; a state of affairs
that has given rise to the adage that “ to the alcoholic all
things are possible/' But before such an ultimatum is
reached a definite and intermediate clinical history will have
been gone through by the vast majority of alcoholics, the
lines of march of these falling in certain fairly distinct and
definite tracts, so that at the onset and in the early and in¬
termediate stages it is possible to arrange the subjects of
these diseases into certain definite natural orders. It is cus¬
tomary among neurologists, who, in the main, deal with the
former kind of case, to state that the symptomatology of the
chronic alcoholic is of the “ extensive and generalized ” kind,
and such is the clinical type portrayed in our text-books
(vide Gowers' “Diseases of the Nervous System," Vol.
II., sub voce Chronic Alcoholism). While these cases are
by no means rare in our asylums, the majority of our alco¬
holic insane are those who belong to the other class in which
the main morbid stress and evolution of symptoms is devel¬
oping in this or that “intensive and specialized way." This
latter is, at any rate, the predominant symptom, though care¬
ful investigation will in some cases reveal the presence also
of the more generalized group of symptoms. The logical
development of the symptoms in our opinion is from (a) the
generalized and extensive to ( b ) the specialized and inten¬
sive, the real fact being that these first vary according to the
personal equation, e . g. f heredity, stress of special sort, etc.,

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Alcohol Insanity .

under which the person lives. Having said this much by
way of making our ground clear, we shall take up the feature
in the onset and morbid evolution of the disease.

The chronic alcoholic exhibits among the early recog¬
nizable symptoms, the following seven main groups :

Generalized and extensive symptoms-complex.

First. Diminished power of recollection (amnesia), i. e.>
of revivifying past mental images or ideas.

Second, Diminished power of attention and volition,
i. e. } in sensorial or kinaesthetic spheres, including their inter¬
connections.

Third. Diminished initiativeness and energy in conduct
(correlated to one and two).

Fourth. Diminished muscular power ; trembling (kinaes¬
thetic sphere); muscular act (kinaesthetic center) requiring
to be reinforced by other sensory stimuli for efficient execu¬
tion.

Fifth. Blunting of higher moral and ethical sense.

Sixth . Insomnia ; loss of capacity for sleep and recu¬
peration (i. e.y nutritive breakdown of the whole cortical
sphere).

Seventh. Serious disturbance in the balance of cortical
representation of external world and empirical ego, with mel¬
ancholia and suspicion, delusions of persecution, and excite¬
ment, hallucinations, vague and gloomy feelings, and other
pathetic emotional states, suicidal tendencies, passing into
various chronic insanities.

We shall consider these groups of symptom groups
seriatim: —

( a ) Diminished power of recollection (amnesic type).
Under the law of psychogenesis we had previously noted
that the power of recalling past memories — of re-visualizing
things seen, of re-hearing things heard, and of re-represent¬
ing previous mental images — imply a highly evolved corti¬
cal (mental) organization, and that it has behind it a nutri¬
tive law of deep significance, under which “ the external
logic of events is now no longer a sine qud non needed to

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Alcohol Insanity .

revivify them. They arise spontaneously, they become re¬
called thoughts, memories. Thus, thoughts arise in the
child’s mind. The feeling of spontaneity which accompanies
these thoughts gradually get built up into the distinct recog¬
nition of the ego as the empirical source and center of such
feelings.” This capacity depends upon the integrity, there¬
fore, of the cerebral organization in two regards, viz., (a) the
integrity of the latest evolved and elaborated anatomico-
physiological connections between the neurons which sub¬
serve it, and ( b) the high nutritive elaboration, the high
“ nerve tension ” and capacity for spontaneous discharge of
the said neurons from time to time. Though these two are
not separate, yet we shall consider them separately in order
to be able to apprehend more clearly the pathogenesis of
amnesia. In what respect does alcohol produce changes in
these, viz., first, in the anatomico-physiological connections,
or “field of conjunction” between the neurons, and second,
in the higher nutrition of each individual neuron.

The results of our investigation with Golgi's method
show us that definite and recognizable changes occur in
each of these respects.

Changes in the anatomico-physiological connections (or
“ field of conjunction ”) between the neurons . Since the exact
nature of such connections in health has been proved indis¬
putably by the application of Golgi’s method, it remains to
inquire how and to what extent these are altered or de¬
stroyed, if at all. Our observations show that change of a
very striking and unmistakable character occurs in the ulti¬
mate protoplasmic expansions and “ contact-granules ” sit¬
uated upon them on the one hand, and in the ultimate naked
fibrils (collaterals and terminals) which everywhere come
into relation with such protoplasmic termini and granules on
the other. Beginning with a softening and swelling of these
contact granules, and also of the protoplasmic twigs on
which they are situated, the earliest noticeable changes are
a coalescence of these into small irregular “ composites ” of
such, recognizable here and there as a local coarseness. As

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Alcohol Insanity .

the changes progress in coarseness and extent, they can now
be more easily recognized as commencing moniliform swell¬
ings along the course of the terminal protoplasmic twigs.
These are chiefly seen in the alcoholic brains we have exam¬
ined with Golgi’s method in the superficial parts of the
cortex—molecular and sub-molecular plexus regions espe¬
cially. With the further progress of the lesion these soft¬
ened and enlarged protoplasmic masses form irregular bo-
tryoidal masses, mainly clothing the now irregularly bared
protoplasmic stem, which itself rapidly becomes softened,
attenuated, and excavated (vacuolated) in places, till finally
what is left is a mere ghost-like tattered protoplasmic stump,
such as some of the cells exhibit. These changes affect the
apical expansions of both ambiguous, long pyramidal, and
mixed pyramidal or polymorphic cells, and the chief stress of
the lesions fall in the region of the molecular and sub-mole¬
cular plexuses, and in the sub-pyramidal plexus region. In
the latter (and below) we come for the first time on the
mixed pyramidal cells, and these show further changes, ex¬
tending to the cell body itself, and remarkably striking in
character. We are speaking of brains in which there is as
yet no vascular blockings, and consequent softenings, for
such we have purposely excluded from the present research,
as the changes were too grossly secondary and advanced.
The changes we now refer to are such as appear in this or
that group of cells, when other cells in a part of the convo¬
lution a few millimetres off will appear but very slightly dis¬
eased. These changes consist in a gradual disintegration of
the cell body ; after the apical several of, the basilar pro¬
cesses have considerably suffered. Here and there at the
side of the cell body the protoplasm seems to get frayed,
and, as it were, eroded or ulcerated away, the site of such
being a local excavation of the cell protoplasm, with an adja¬
cent little heap of debris . In other cells these changes will
start from several points on the surface of the cell body
irregularly eroding and demolishing it, until but small frag¬
ments of the cell, mere ruins, with a little debris , are left in

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Alcohol Insanity.

the pericellular sac. Such a cell, in which the destructive
process has yet left its axis-cylinder and a few withered bas¬
ilar-protoplasmic processes is seen. In other cases, again,
the cell-protoplasm gets vacuolated from within, and the
progress of this continues till its whole internal protoplasmic
structure is channeled and tunneled by such holes and
seams of liquefaction. We do not mean to correlate early
and recoverable alcoholic amnesia with the advanced de¬
structive changes in the cell body. Rather we look upon it
as associated with the early changes in the fine protoplasmic
contact granules of the apical expansions which we have
already figured and described. The lesions in these fine
protoplasmic granules, however, represent but one element
in the field of conjunction, and we must now refer to the
other element, viz., the fine collaterals and terminals which,
arriving from association, commissural or terminal fibres
spread out in the three main plexus regions, viz., molecular,
sub-molecular, and sub-pyramidal, forming the other element
of the nervo-protoplasmic connections. These have to be
carefully looked for with high powers, as, owing to their ex¬
treme delicacy, and their paleness of staining with silver
chromate, they are else liable to be overlooked. A careful
search, however, will soon reveal the fact that these are
extensively changed and altered. The changes we have
noted are mainly of two kinds , external and internal. Exter¬
nal changes: These refer to the outline and contour of these
fibrils. In health they are fine, delicate, smooth, and clear-
cut in outline, like a thread of silk, and stain internally , with
a uniform clear coffee-colored tint. In disease these become
granular and wrinkled in outline, as though the firm smooth
consistence of the fibre underwent a granulation with soft¬
ening, and lost its cleanness of contour. Here and there,
too, small irregular swellings are seen. Internal changes:
These are very distinct in many specimens, and can leave
no doubt in our mind that chemical alterations are taking
place within the fibril. The most striking feature is discon¬
tinuous and uneven staining. The fine and delicate collat-

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Alcohol Insanity .

eral or terminal fibril, which stained (if it stained at all) of a
uniform clear coffee tint, is irregularly stained along its
course, in some parts the pallor and want of staining almost
indicating that the fibre is broken into separate fragments,
till the most careful focusing and search will reveal the un¬
stained intermediate parts. These streaks of discontinuous
and irregular staining are so remarkably frequent and con¬
spicuous in several specimens we have examined, that we
have no doubt they represent what is a real pathological
change going on within these naked nerve fibrils.

These two sets of changes in the naked collateral and
terminal fibrils (internal and external) constitute, to our
mind, the other element of earliest and recognizable change
in the field of conjunction, whereby the pathways for the
passage of nervous excitations from neuron to neuron, and
from one complex group of neurons (nerve center) to another,
is thus rendered difficult or impossible. Both these sets of
changes in the field of conjunction are, as far as the present
author is aware, only recognizable with the use of Golgi’s
method and its modifications, the author having used for
this purpose his own modification, published in the British
Medical Journal March, 1894. Our work in this line leads
us to the view that it is here, in the changes in the anato-
mico-physiological junction regions, in this field of conjunc¬
tion, we find the earliest dynamical changes, and that these
represent, on the psychical side, the diminished capacity of
the neurons to be excitable to presentative sensorial stimu¬
lations (the equivalent of the softenings and obliterations of
the protoplasmic contact-granules), and a diminished perme¬
ability in the pathways of nerve currents issuing from one
neuron by its nervous process and its terminals to another
neuron in the cortical area, the psychical counterpart of
which would be a slowness in the arousing of associated
images , and delay of reaction time . Finally, as regards the
earlier and subtler nutritive changes within the cell body
and nucleus. The physiology of nutrition is in the nerve
cell elaborated to a high degree, and each nerve center of
Vol. XVIII.— 2

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Alcohol Insanity ..

this or that part of the central nervous system has its own
intrinsic nutritive rhythm. In the alcoholic brain, the early
and subtler changes affect, not merely the field of conjunc¬
tion (produce dynamical effects as far as the reception and
transmission of nerve currents are concerned ), but the trophic
or nutritive focus (cell body and nucleus) of each individual
neuron. The advanced trophic changes, especially as shown
in the polymorphic elements, we have already described and
portrayed. The cells in this region are also favorable for
the study of the commencing trophic changes in the neuron.
The methods* we have used for this purpose are four in num¬
ber: ( a ) sublimate and alcohol fixing, and staining with
Toluidine blue; ( b ) frozen sections, stained with aniline
blue-black ; (r) Nissl’s methylene-blue method ; (d) Golgi's
method. Each of these helps to supplement the other.

Commencing trophic changes in the cell bodies and
nucleus. We are of opinion that these also are definite and
recognizable, and further, that in certain respects (viz.,* as
elucidated by the aniline blue-black method) these have been
abundantly described and figured by Bevan Lewis (“Text¬
book of Mental Disease," 1890). For our own part we
would add certain details obtained by our investigations
with the three other methods named, viz., the Toluidine,
Nissl, and Golgi methods. The first and second of these
methods are useful for showing certain fine intra-cellular and
intra-nuclear changes which the aniline method does not
help to show, while the third enables us to apply a certain
test to identify what fragments of nerve-protoplasm still re¬
main. Fortunately for us, not all the cells show equaliy ad¬
vanced changes in the alcoholic brain, for while some show
moderately advanced intra-cellular changes at once recogni¬
zable as such, others (neighboring cells) on whom the stress
— for some reason or other — has not fallen so severely will
show us appearances consistent with health, or only faint in¬
dications of a commencing departure from the normal. This
graduation of pathological changes helps us greatly, for it
offers an intrinsic control method of distinct value. Keeping

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Alcohol Insanity .

this in mind the earliest changes we see are: (a) Deeper
staining, of cell body and protoplasmic processes (with ani¬
line, Toluidine, and Nissl’s method), (b) Swelling and soft¬
ening (indistinctness of outline) of the intra-cellular chroma¬
tin rods, and increased intensity of their staining (with Nissl’s
method), {c) Thickening of intra-nuclear reticulum, and
increased prominence of nucleoli (with Toluidine method).
(d) Increase of the normal golden cell pigment which is
present at or near the basal portion of the cell (with all three
methods). We are not as yet in a position to state which
of these four changes occurs first, or whether any two or
more of them occur simultaneously; but certainly they all
occur in the earliest stages, when the contemporaneous
changes in the finest nervo-protoplasmic regions which we
have before detailed occur. To ys these four points men¬
tioned indicate two things, viz.: (a) that there is increased
functional activity in the cell body, and (b) that this is pro¬
ductive of a degradation in the form of nerve energy, the
physical accompaniment of which is a softening and altera¬
tion of the blue chromatin rods and granules, and their grad¬
ual replacement by yellowish pigment. The increase and
progress of pigmentation is the equivalent of the onset and
progress of degradation in the functional activity of the cell
— the replacement of living protoplasm by non-living pig¬
mentary product as in senile decay and in chronic epilepsy:
here (in chronic alcoholism) it is attended with the other
intra-cellular changes of a more subtle kind, viz., intensity of
staining of cell protoplasm, and swelling and softening with
increased staining of the intra-cellular chromatin rods and
granules, the reservoirs for the building up and storage of
nerve energy under high tension, i. *., the pabulum of the
cell. The earliest lesions, therefore, of alcoholism are of a
nutritive and dynamical type, dynamical in so far as it affects
the protoplasmic granules on the one hand and the nerve col¬
laterals and terminals on the other which enter into the con¬
stitution of the nervo-protoplasmic plexuses (fields of con¬
junction) in the brain ; and nutritional in so far as it affects

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Alcohol Insanity .

the protoplasm and nucleus of the cell body and therefore in¬
terferes with the higher evolution and elaboration of nerve
energy, and especially with the quasi-spontaneous or volun¬
tary vivifications of former memory images which is the pe¬
culiar property of the cortical neuron during its period of
increased functional activity.

But this is not the only result of the alcoholic lesion.
Another outcome of it is the next group of symptoms.

( b ) Diminished faculty of attention and volition .

Here there is a slightly deeper involvement, we think.
In the mild amnesia we have considered there is the loss
of re-vivification or re-rousing of past experienced mental
images and states; here, even when the objective images
are present, the capacity of receiving and registering them in
the mind is diminished. J3n the psychical side this is, in
other words, diminished power of attention. It may be that
in one case this is mainly limited to the visual, in another
to the olfactory, in a third to the kinaesthetic, or in a fourth,
etc., to the auditory, etc., sphere, and that in other cases it
extends to all these. The faculty of attention is an early
one in the infant, and we think it is simpler in character
and grade than volition. At least two sensorial elements
enter into the composition of attention, viz. : (a) the special
or local sense which is being active; ( b ) its special
kinaesthetic auxiliary. The mode of evolution of each
special or local sense has been a twin evolution, a special
kinaesthetic element having entered into it, and got incor¬
porated with it. With sight there is the representation of
the movement mechanism, which is concerned in fixing an
object seen, in bringing it into the field of clear vision
before it can be the special object of attention. With it
comes accommodation , which is also brought to bear on the
object. Besides these bin-ocular and intra-ocular kinaeses a
head movement may also enter into the primary constitu¬
tion of attention to a visual impression (turning the head
towards it), cfi also auditory attention and movements of
the ears. This is the primary kinetic reaction, appearing

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early in the animal kingdom, and early in the child. It is
forerunner of and prerequisite for attention.

So in hearing there is the external ear movement and the
internal one (tensor tympani), these kinetic elements enter¬
ing into the composition of auditory attention. So with
smell (nostril and respiratory indrawing as in the child on
its mother’s breast, etc.). And with touch or tactile there is
a parallel incorporation of a movement sense of the organs
of touch (the fingers, hand, etc.).

Attention is thus analyzable into a compound or complex
of at least two sensory elements ; therefore it is a higher
sensory state (psychical state), and is the psychical con¬
comitant of nervous action in such conjoint sensorial sphere.
The feeling of effort enters into both attention and volition,
and this has misled some to speak of the act of attention as
an essentially “motor” process. But this is due to a
little confusion of ideas. The sense of sight, of hearing,
the tactile sense, the muscular sense, etc., each of these has
its appropriate auxiliary muscular organs, the function of
which has been to produce a movement in the peripheral
sense organ. This has been so constant a thing that from
frequent repetition their organization has become perfect,
until in man the motor action is habitual and follows the
sensation. Thus according to our view every sensory organ
has its auxiliary muscles which by their aid help to reinforce
its function. The cycle of events is: (a) Stimulations of
cortical sensory center = consciousness of sensation. (£)
Movement following, whereby the external object is brought
into the center or focus of the field of consciousness by
pricking of ears, fixing with eye, etc. ( c ) As the result of
(a) and (<5), stronger arousal of cortical sensory center by the
re-entering sensory currents both from the sensory organ
and its auxiliary muscles. Such re-entering of auxiliary
kinaesthetic currents serves to reinforce and increase the
functional activity of the sensory center. The psychical
side of such intensification of the activity of the sensory
center is attention. Hence we cannot localize the faculty

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of attention in any one “ area ” of the brain (as e . g. t Ferrier,
in the pre-frontal lobe in monkeys). It accompanies, and
can accompany the activity or any of the specific centers of
sensation, whether visual, auditory, tactile, gustatory, olfac¬
tory, or kinaesthetic. There is no special center for the
faculty of attention.

Now the above heightening of the functional activity of
a sensory center has for its object some act immediate or
future on the part of the organism in response to the
sensation which is now distinctly felt. It may be now one,
or it may be at another time other act, according to the
dynamical (anatomico-physiological) connections possessed
by the sensory center which is in a state of such increased
functional activity.

During the condition of attention there is thus not only
an increased functional activity in this or that sensory center,
but an overflow or discharge from that center to others along
definite routes, or diffusely all over its borders. Where a
voluntary act or movement is one of the outcomes, the
neural discharges consist of ( a ) primary sensation, focus-
ing-reflex, and attention ; and (< b ) discharge from such sensory
center, (c) with resultant excitation of other sensory or
psychical centers, arousing feelings and mental images
(ideas), or of a kinaesthetic center, in the last case evoking a
more or less obviously special movement. The sequence of
events comprise, therefore, (a) arousing a sensory center to
attention; and its discharge, along (£) a tract to (c) a
kinaesthetic center; followed by an appropriate movement
to its completion, or, in psychological language, first , per¬
ception ; second , apperception and attention; third , strong
revival in mind of the act to be performed ; fourth , execution
of the idea.

Attention thus belongs to the sensory side; volition to
a specialized and intensive discharge therefrom to the kin¬
aesthetic sphere. Volition is thus a development from atten¬
tion, and passes on to execution ; it is thus the passing from
attention to execution: in the brain it overlaps the psycho-

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motor sphere on the one side, and the sensory on the other;
its region is, therefore, the transitional or association system
one between these two.

On the anatomico-physiological side we think the mixed
pyramidal or polymorphic system to chiefly represent this
association region, partly on comparative and developmental
grounds, and partly from pathological considerations. The
gradual historical development and elaboration of this system
in the mammal, till it attains its acme in man, and the late¬
ness of this lower cortical organization to complete its
growth in the new-born and young indicate that this “ acces¬
sory association system ” of the brain is the chief structure
which subserves the higher psychical functions, and especi¬
ally volition. Further, of all the various cell systems involved
in chronic alcoholism, it is the one in which the changes —
especially the trophic ones — are most advanced.

We therefore correlate its special implication and various
before-described phases and early change with the special
neurasthenia of the alcoholic, including the next group of
symptoms on our list—diminution of initiativeness in con¬
duct, and laziness with blunted moral and ethical sense be¬
hind these.

Coming next we have a definite group of symptoms, viz.:
( a ) loss of muscular power, with tremor on exertion. We
regard this special condition as due to lesions in the kinaes-
thetic area, affecting both the dynamical and nutritive parts
of the nerve apparatus; i. e. y both nervo-protoplasmic con¬
nections and cell bodies. Indeed, this Rolandic (or move¬
ment) sphere is the commonly used one for its study because
the cell elements are large and easy, therefore, for study in
this situation ; and perhaps because the further progress of
the lesions are apparently more conspicuous and striking
here ( e . g. y atrophy and wasting of convolutions : oedema and
thickening of pia-arachnoid, etc.). We have seen in studying
the development of the Rolandic region in the young how
the increased growth and extent of collaterals from the
descending axis-cylinders of the ambiguous and pyramidal

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cells, and their coming into further contact with the proto¬
plasmic expansions of the lower and larger pyramidal cells
constitute a special intrinsic mechanism for the consolida¬
tion of movements. These collaterals conspicuously suffer,
viz., in the Rolandic area, and to this we attribute the tremor
and unsteadiness (dynamical disturbance) in movement.
Apart from this tremor there is a true weakness , as shown
with the dynamometer, which may amount to a paresis of
20-40 p. c. below health.

We correlate this with the commencing nutritive degra¬
dation of the nerve cells which discharge down the pyramidal
track, inciting thereby the motor cells of the cord. It is,
we think, a phenomenon parallel to the muscular weakness
of neurasthesia when tested with the dynamometer. This
combination of tremor and weakness are the basis for the
dyskinaesis of alcoholism.

The reinforcement these cells require, even to enable
them to act continuously for a time, should be noted. The
alcoholic holding a ball or jug in his hand will often drop it
if he be not looking — fixing his attention — on it. For the
normal tactile and kinaesthetic ascending currents arrived at
the brain, have to act on pyscho-motor cells of but low
energy which may flag. By looking at the object (attention)
the sensorial visual excitations arrive after passing the
visual center, to the hand center, and reinforce the volume of
the sensory exciting currents which keep up the functional
activity of the psycho-motor cells. The phenomenon here
is also analogous to that of subminimal stimulation of the
cortex, which, though of itself failing to evoke movement
from the kinaesthetic focus, will do so if the paw be first
stroked gently a few times, and then the electrodes applied.
The center thus slightly roused in its excitability now just
reacts. Instead of the paw the stimulus of some associated
area (e. g ,, smell) will also serve the same purpose, viz.,
heightening the excitability of the kinaesthetic center. (In
this connection, note also Belmondo's experiments on the
spinal cord motor cells associated with stimulation of the

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posterior roots, Arckiv . Ital. de Biol. % 1891, Part I.), which
also fall into a similar category.

( b) Insotnania. This is another of the early alcoholic
symptoms. How far this may be due to habit it is difficult
to say. But its injurious effect on the brain is certain. We
know from physiological experiments that cell elements,
whether secretory or motor, exhibit physico-chemical changes
during activity: e. g., electric changes and changes in intra¬
cellular structure. When pushed to the limits of fatigue,
these changes in the secreting cells , the muscle fibre , or the
moter end plate of the nerve are not too difficult to recognize.
A pseudo-sanctity which has hitherto surrounded the nerve
cell and sought to exclude it from the circle of these meta¬
bolic changes is now breaking down, and of late years the
experimental work of cerebral thermometry (Mosso), and of
the microscopic changes in nerve cells accompanying func¬
tional activity (Hodge and others) have gradually brought a
series of positive facts to displace the old superstition.

Hodge’s work in this respect, following on the older
observations of Sadovski and others, shows that in the cere¬
bral cells of the honey-bee, swallow, pigeon, and sparrow,
such recognizable changes are found. To summarize them,
and finds ( a ) changes in the nucleus, viz., shrinkage, and
crenation of outline, loss of fine intra-nuclear reticulation,
and tendency of the nuclear chromatin to stain more darkly
than during rest. His experiments were extensive, carefully
and laboriously done with abundance of control material, and
the results obtained are regular and very uniform. Besides
these intra-nuclear changes, there are ( b) the alterations in
the cell protoplasm: these include shrinkage in size of the
cell with (in the case of the cerebral cells) enlargement of
the peri-cellular lymph space, commencing vacuolation in the
cell protoplasm, and diminished staining reaction of the
fatigued cell. The present author having been favored with
the actual microscopic specimens from Dr. Hodge, can en¬
tirely concur in the above statement of facts as borne out by
the preparations. This subject has also a further interest
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owing to the researches of Dr. Batty Tuke, who, with Dr.
Mann, has investigated the changes underlying fatigue in
the bipolar cells of the retina (second layer), and in the
occipital lobe of the rabbit in connection with visual stimula¬
tion, as well as the changes in the cells of cervical ganglion
also, during fatigue induced by stimulation of the sympathetic
cord lower down. The specimens and micro-photographs
which illustrate their research (yet unpublished) leave no
doubt that a series of changes parallel to those described by
Dr. Hodge are present beyond doubt. Their conclusions I
present in Dr. Tuke’s own words: “ In the unstimulated cell
the nucleus stains lighter than the protoplasm ; the first
effect of stimulation is to reduce the staining of both to the
same degree of intensity; as it is continued the nucleus
darkens, but remains lighter than the protoplasm ; then the
nucleus becomes distinctly darker, and begins to get de¬
formed and crenated; and eventually a condition is produced
which may be spoken of as a collapse, nucleus and pro¬
toplasm losing all power of taking on stains.” The third
stage, in which there is the conspicuous dark staining of the
nucleus, as well as of the cell protoplasm, and in which the
nucleus itself begins to get deformed and crenated is stated
by Dr. Batty Tuke to be the “ limit of functional activity
changes.” Experimentally it has been reached after eighteen
hours’ continuous excitation of the cell, and marks the
borderland where the whole pabulum or nutritive material of
the cell body is used up, and yet leaves the organ in a condi¬
tion admitting of reconstruction (recuperation). A fourth
stage, according to the same observer, marks the pathologi¬
cal, the condition of actual or commencing vacuolation and
disintegration within the cell protoplasm “ from which it is
doubtful whether full recuperation can be obtained.” The
consensus of results obtained from the work therefore of
Heidenhain, Langley, and others on glandular secreting cells,
of Kodis, on cells of the epidermis, Sadovski (“ On the
Changes of Nerve Centers caused by Peripheral Irritation,’*
1889), and Madame Ternonski (“ Changes in the Spinal

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Cord due to stretching of the Sciatic Nerve, etc.,” 1885), on
spinal ganglia and the cells of the spinal cord, and the more
recent work of Lambert and of Vas on the sympathetic
ganglia, and of Hodge on nerve cells (“A Microscopical Study
of Changes due to functional activity in Nerve Cells,” 1892),
and of Drs. Batty Tuke and Mann (on the same subject,
1893-4) form a growing body of definite and well-ascertained
facts which the present author thinks will have the profound-
est bearing on the scientific basis for practical treatment in
neurasthenia, insomnia, and fatigue, with commencing break¬
down, which mark the milestones along the high road to the
ultimate development of the various alcoholic insanities, the
melancholias and the various other protean brain and nervous
maladies which are so abundant in our decade.

And this leads us now to the next group of symptoms-
complex in our general consideration of the alcoholic group
of the insanities, which completes our general survey, viz.:

Melancholia with suspicion, vague dreads, mixed with
phases of momentary excitement, and finally of acute halluci¬
nations and delusions, maniacal excitement, delirious condi¬
tions, and epileptic fits, from which, if relief is obtained, a
permanent residuum of weakmindedness is left behind, or
of chronic mania or systematized delusional insanity. The
earliest in this group is melancholia, with vague and general
suspicions, intensified at moments with distinct hallucina¬
tions of the senses. It is at this stage that most of our
asylum alcoholics come under observation, having at home
passed through the previous six stages. This, the seventh
stage, is one of bad omen. It indicates not only a serious
progress of the mischief beyond the limits where, according
to Batty Tuke, repair is possible, but is very often the begin¬
ning of a downward progressive stage of peculiar malignancy,
most unsatisfactory to treat, and very disheartening in its
sequelae. Of course all parts of the higher cerebral organiza¬
tion have not suffered equally in these cases; the clinical
and psychological indications they exhibit prove this. But
though the patient be placed under good hygienic conditions,

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18 Alcohol Insanity .

with rest, abundant food, and absence of worry and anxiety,
and the administration of sedatives to procure sleep, of mass¬
age for the body tissues, and even of intestinal asepsis, in
the vast majority of cases the capacities for recuperation
have been passed, and their march and progress is towards
systematized and chronic insanity.

Considerable extents of cortical tissue have been dam¬
aged beyond repair: points of softening and breaking up in
the molecular and sub-molecular nervo-protoplasmic plexuses,
and a more notable involvement in the sub-pyramidal region
(polymorphic system) with pigmentary and fatty degenera¬
tions of nerve cells, cutting off and complete degeneration of
one or more entire basilar protoplasmic processes or of the
whole apical process, and similarly to crown all a vascular
disease (endo-arteritis and fatty changes with narrowing of
lumina of cerebral blood vessels) with its sequelae, viz.: im¬
perfect nutrition of the brain tissue, thrombosis and focal
softenings which complete the picture of progressive rotten¬
ness and disintegration of brain tissue which can never be
recovered from. This stage is associated with softenings
and swellings in the neuroglia elements themselves, with
vacuolation of their cell protoplasm, with pigmentation of
the cell body, with swellings of the processes, and the abund¬
ant formation of so-called colloid bodies in the brain. Our
observations show us that in a considerable number of cases
these latter structures, viz.: “colloid bodies,” are derivatives
of the neuroglia fibre cells, as revealed by the method of
staining with silver chromate. They are to be met with in
all sizes, from the smallest recognizable speck situated on a
delicate neuroglia fibre to a considerable swelling or series of
beaded swellings occurring along the course of the same
neuroglia fibres. As to their origin in medullated fibres
from swellings and spherules of the myelin substance, our
observations give no indication (negative evidence), but it
leaves no doubt in our minds, in so far as the sharpness and
precision of staining with Golgi’s method leaves no possible
ground for doubt, that at least one source of their origin is

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the neuroglia element — the fibre-cell. In the surface con¬
densation system of neuroglia fibre, in a region where, the
medullation fibres are absent, these bodies can be recognized
in all sizes from the minutest to the largest met with. Is it
not singular that according to the view of the origin of
these bodies from myelin, these bodies should be rare and
conspicuous by their absence from the very heart and center
of Exner’s plexus, where medullated fibres abound, whereas
when we pass more superficially through the “ clear zone ”
and enter into the substance of the tangential plexus of
neuroglia fibres, that here, in a region barren and devoid of
medullation nerve fibres, but abounding in neuroglia fibres,
these colloid bodies should be abundant? We have also
noted their presence in the ependyma in connection with
the special layer of stellate cells in the subepithelial region,
these bodies being undoubtedly in this region caused by
swellings along the processes of these stellate fibre cells.
With alumhaematoxylin we have confirmed the statement of
Obersteiner that they stain a fine blue color, and their deep
violet reaction when treated with iodine, followed by dilute
sulphuric acid. With Ranviers picro-carmine they also stain
darkly, but not with aniline blue-black. Chemically we re¬
gard them as coming closest to the eleidin granules discov¬
ered by Ranvier in the epidermis. We have now in the
briefest manner to touch upon the specialized and intensive
lesions in chronic alcoholic insanity to finish our general
survey of the law of pathogenesis.

Specialized and Intensive Pathological Types of Alco¬
holic Insanity .—The subjects of these have a neurotic her¬
itage, epileptic, intemperate, and criminaloid. The early
and severe implication of certain regions of the cortical or¬
ganization in these betrays to us a significant fact, that the
vice is in the nerve cell; the cell is the selective agent, so to
speak. Under stress of another kind, e.g ., worry, sexual ex¬
cess, etc., the result would have been a form of downbreak
(disorganization) of a similar sort (*. g. y melancholia and de¬
lusional insanity) to what it would be under alcoholic stress.

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We must recognize the intrinsic hereditary vice of organiza¬
tion of the nerve cell; giving to alcohol, syphilis, sexual ex¬
cess, worry, etc., or other external facts, its subordinate po¬
sition as an element of stress which, whether acting directly
as a chemical poison or indirectly, via the peripheral nerves,
is but an auxiliary in bringing out the intrinsic cerebral de¬
fect. The intrinsic vice of organization is within, and re¬
quires but little stress of circumstances to reveal itself. In
these subjects the “generalized and extensive” group of
symptoms before mentioned is rapidly passed over or abbre¬
viated, and the special and intense insane involvement early
makes its appearance, viz., melancholia with persecutory de¬
lusions (two-thirds of the total number of cases) with or with¬
out ideas of grandeur, varied by outbursts of acute excite¬
ment (mania), in which acute hallucinations may play at
times a casual part. These hallucinations and delusions may
be aural , visual , olfactory, cutaneous , gastric and abdominal ,
genito-urinary , etc., or several of these combined, in fact the
most protean and multiform that could be imagined, and hav¬
ing affinities with the more rapidly evolving G. P. on the one
hand, and the more slowly developing paranoiac on the other,
and equally with those of hopeless prognosis.

We have now concluded our brief survey of the law of
pathogenesis, which in a future publication we intend to deal
with in greater detail than is possible within the limits of the
present paper. We have seen how the onset and early
course present all the phenomena comparable to fatigue con¬
ditions of the nerve cells, and that when these nutritive
changes pass a certain limit, the manifestations of insanity
commence. We have seen also how, with the invoivements
of the delicate collateral and terminal fibrils and protoplasmic
granules which enter into the dynamical constitution of the
cortical centers, this general diminution of brain power will
be accompanied by sensory, psychical, and kinaesthetic clin-
cal symptoms of a very distinct and definite kind, and how,
with the added vice of hereditary taint, the law of psychogen¬
esis finds its rapid and full realization in the various delu-

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sional and melancholic states, with alternating phases of
gloom and excitement, which passes on by natural evolution
to the more hopeless and helpless grades of insanity.

From the whole body of the foregoing research and discus¬
sion, long and tedious as it has been, the following conclu¬
sions are therefore drawn :—

GENERAL CONCLUSIONS.

First . The doctrine of localization of functions in the
brain is the basis which renders a study of the psychology
and pathology of insanity possible, and especially the ex¬
tension of the function to the “ neuron ” the unit of nervous
and psychical function considered from every point of view.

Second . All nervous mechanisms of the bulbo-spinal type
are organized on a common fundamental basis, and consist
of at least two nerve elements—a sensitive epithelial bipolar
cell, and a central motor element. Over and above these an
intermediate system of cells may be developed, subserving
a great variety of functions in all vertebrates.

Third. These intermediate cells of the bulbo-spinal axis
allow of co-ordination and correlation of activities between
the various metameric segments of the bulbo-spinal tube, and
between the several bulbo-spinal centers on the one hand and
the encephalic organs on the other.

Fourth. There is an actual and demonstrable basis of
structure in the bulbo-spinal system which allows of a great
variety in so-called reflex movements; some of these latter
being sufficiently elaborate to almost deserve the name “ pur¬
posive.”

Fifth . The cerebral system is a growth and elaboration
of neurons in connection with three great sensory projection
systems, viz., the olfactory , the optic, and the bulbo-spinal
(this last including within itself tactile , gustatory, kincesthe -
tic , and other sensory projection systems).

Sixth . The cerebral system has developed at that part
of the organism which led in locomotion, was the first to
come into contact with the environment, and whose sensi-

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Alcohol Insanity.

tiveness and reactiveness would therefore be the most highly
developed in the organism. It is a region, therefore, towards
which not only ganglionic concentration takes place, but in
which the higher and more complex nerve mechanisms con¬
tinue in a growing and therefore more plastic state; a highly
educable nerve organization.

Seventh . The cortical mechanism or pallium arises in
the scale of mass (quantity) and internal elaboration (qual¬
ity) as we pass from the amphibian, via the reptilian, to the
mammalian series, finally attaining its highest quantitative
and qualitative evolution in man. It becomes the seat and
organ of every form and quality of psychical life.

Eighth. The elements which enter into the cerebral or¬
ganization in man are the ultimate product of a long series of
evolutions in structure and function through countless ages
past. These elements are mainly of three kinds, nervous
protective , and nutritive.

Ninth. The cerebral nervous elements (neurons) are
separate and distinct anatomically; they do not anastomose
one with another, but function only by contact. The indi¬
vidual neuron is a three-fold mechanism, its protoplasmic and
nervous processes constituting the two parts which enter into
dynamical relationship with other neurons, while the cell pro¬
toplasm and nucleus constitute the highly-evolved and spe¬
cialized trophic and nutritive focus of the whole.

Tenth. The cerebral cortex in man is composed of
various cell elements disposed in layers ; of these there are
four main systems, viz.: the molecular, ambiguous, long pyr¬
amidal, and polymorphic, each having its special anatomico-
physiological characters.

Eleventh. The sensory excitations passing upwards to
the cortex by projection fibres, mainly spread and get distri¬
buted in the molecular and sub-molecular regions, affecting
thereby both ambiguous cells and long pyramidal cells. This
is true of the olfactory and optic projections, and probably
true also of the fillet radiations.

Twelfth. While the main fibres and branches of such

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sensory projection systems are medullated and insulated, the
insulation ceases in the “field of conjunction,” or nervo-pro-
toplasmic plexuses of the molecular and sub-ambiguozis re¬
gions. Here the “ naked ” collaterals and terminals of these
fibres come into the most intimate contact with the enor¬
mous expanse of protoplasmic branches and twigs which ram¬
ify in those plexus regions.

Thirteenth . A sub-pyramidal nervo-protoplasmic plexus
is also formed in the cortex to further increase and perfect
the various intrinsic association and commissural systems in
the brain.

Fourteenth . That as we rise in the vertebrate scale to the
mammalia, a new sub-cortical system of elements (polymor¬
phic cells) is developed. This is even in early life still un¬
dergoing demonstrable evolution. It is to be looked upon,
therefore, as the latest portion of the cerebral organization,
and one distinctive of the mammalian brain.

Fifteenth . That the whole system of association and
commissural fibres grows in accordance with the degree of
brain evolution, and that these, together with the polymorphic
cell elements, attain their highest relative and absolute evo¬
lution in the human brain.

Sixteenth. That the specific natures of psychical pro¬
cesses depend upon the specific activities in the various sen¬
sorial “ areas ” of the cortex, and that the latter are to a cer¬
tain extent localizable. That the whole body of anatomico-
physiological and pathological evidence demonstrates such
localization of function ; and that the Golgi method enables
us to push this localization further, at least as regards the
the kinds of cortical nerve elements, which are the first to
subserve sensorial activities.

Seventeenth. That in disease such centers (according to
the locality of the disease) may be the seat of visual, audi¬
tory, gustatory, tactile, and cutaneous, olfactory or kinaes-
thetic discharges (hallucinations and Jacksonian epilepsies);
and that similarly more extensive and higher cortical areas
may be involved, giving rise to “psychical epilepsies.”

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Eighteenth. That recent evidence and facts tend to show
that the Rolandic area is the seat of sensory processes
mainly belonging to the kinaesthetic order, concerned, there¬
fore, with the executive activities (bodily acts) of the organism
in relation to or in adjustment to the environment; and that
the whole Rolandic area thus is the finally disposed executive
mechanism as far as the brain is concerned.

Nineteenth. That the study of the aphasias show that
according as various cortical centers and tracts are the locus
of the lesion, the clinico-pscyhological symptoms vary. The
whole body of evidence so far considered in our paper shows
that the cerebral cortex is the seat of various psychological
activities not only differing in kind, but different also in the
form and extent of their elaboration.

Twentieth . That in the Rolandic (kinaesthetic) area a
structural evolution is at the root of, and accompanies the
functional evolution of movements and acts, the progress of
the nerve organization being parallel to the progress of move¬
ments from dyskinaesis to cukinaesis. A similar anatomico-
physiological evolution of the cortex takes place in other
areas.

Twenty-first . That according to the nature of this ana-
tomico-physiological growth of the brain, it is capable of re¬
ceiving new impressions and is within certain limits plastic
and educable, not a rigidly pre-established structure.

Twenty-second. That quality (extent and complexity) of
organization in the brain is the real basis of intellectual
(mental) capacity, and not mere quantity or mass ; that thus
a brain small in size (like that of Gambetta) may from its in¬
trinsic high elaboration be able to subserve more varied, ex¬
tensive and multiform activities in life and thought than oth¬
ers of grosser organization, even if blessed with greater size,
can be capable of.

Twenty-third. That the law of psychogenesis takes
place in the child not only in the psycho-motor and sensu¬
ous, but also in the intellectual (relational) sphere which
combines these two, following very definite lines, and that

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Alcohol Insanity . 25

during such stages the child is peculiarly impressionable to
surroundings.

Twenty fourth. That the evolution of language as an in¬
strument for the reinforcement of psychical activities (which,
however, can take place in its absence) co-operates greatly
in brain development. It allows the child to represent
the most varied and different things in terms of a common
denominator; it is thus of the highest formal value in the
exercises and repetitions of psychical processes which under¬
lie mental evolution.

Twenty-fifth. The gradual recognition of the empirical
ego as the center and source of spontaneous activities and
its distinction from and antagonism to the external world,
are the bases of self-consciousness, self-assertiveness, and
volition; the higher states of self-sacrifice and altruism
arising later (during and after adolescence) in human char¬
acter.

Twenty-sixth. That under the law of pathogenesis many
of these early evolutions in brain and mind, from the foetal to
the adolescent stage, may undergo alteration (perversion)
or defect (absence), and that such pathological conditions of
the organism are the basis of the insanities.

Twenty-seventh. That besides lesions in the nerve ele¬
ments proper, lesions may occur either in the special protec¬
tive or the nutritive mechanisms of the nervous system,
which we have fully described before, furnishing additional
bases towards pathogenesis.

Twenty-eighth. That the whole course of clinico-psycho-
logical and pathological evolution in the early stages of an
insanity of slow development like alcoholic insanity, enables
us to recognize two great classes or types, in one of which the
morbid changes are more generalized and extensive , while in
others this first stage is slight or abbreviated, and a special¬
ized and intensive development of pathological changes takes
place.

Twenty-ninth. That it is possible to correlate the early
pathological (internal) changes taking place in the brain

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Alcohol Insanity .

with the early clinico-psychological symptoms of the alco¬
holic insanities, viz. : amnesia, diminished power of attention
and volition, diminished initiativeness and energy in con¬
duct, muscular weakness and tremor, and insomnia, and that
the further progress of the morbid changes in the brain in as¬
sociation with the psychical conditions of melancholia, with
delusions of suspicion, acute hallucinations, maniacal and epi¬
leptiform outbursts, are of a more protean but also more ad¬
vanced type, in which serious destructions (disorganizations)
occur chiefly in the nervo-protoplasmic plexuses of the molec¬
ular and ambiguous regions on the one hand and in the poly¬
morphic elements on the other; in these cases the nutritive
changes zvithin the cell-protoplasm and nucleus being also
advanced beyond the limits of repair, the changes in the non-
nervous elements being also far advanced.

Thirtieth. That the whole of the above body of neuro¬
logical and pathological evidence, together with recent ex¬
perimental work, show that in the early stages of the insani¬
ties there is a profound nutritive and dynamical failure in the
nerve elements of the brain, which finds expression in the
insomnias, the melancholias, and the commencing loss of
memory, with easily induced mental fatigue which their sub¬
jects experience, and that the pathological facts ascertained,
in so far as they afford us any light, force on us the convic¬
tion that we are dealing with serious nutritive and dynamical
changes in the central nervous organ, a conviction which
must profoundly influence the clinical study and practical
treatment of insanity in the future more than it has in the
past.

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Treatment of Delirium Tremens.

2 7

TREATMENT OF DELIRIUM TREMENS*

By Dr. Norman Kerr, London, England.

Of the treatment there has been no end. Not so very
long ago all cases were freely plied with alcoholic beverages
from outset to finish. The question used to be, not “ Shall
this patient have an intoxicant ? but “What stimulant shall
he get ? ” the practice being to give liberal quantities often
of both wines and spirits. During the past thirty-five years
or so, the superstition on which this treatment was based,
that it was perilous to cut off alcohol at once, has gradually
been exploded, though the writer has now and then met
with patients whose attending practitioner has shrunk with
horror at the risk involved in “so dangerous a step.” By re¬
spectable authorities we are even now gravely assured that
in serious cases it is imperative to continue to give the
patient the same intoxicating drinks in which he has been
accustomed to indulge, and that it is a mistake to suddenly
withdraw the liquor.

An experience of some hundreds of cases has shown the
writer that this is an erroneous belief. In, this disease he
has never seen the liquor do anything but decided harm, in
some instances putting in jeopardy the safety of the patient,
in other instances contributing to a fatal issue. Both by
their direct effects and by their influence in reaction, alco¬
holic drinks are injurious.

The patient is laboring under a toxaemia induced by alco¬
hol, and to keep giving him more of the poisoning agent is to
keep up the toxic action. He is being weakened by the ex¬
cessive and prolonged discharge of nerve energy, and by his
muscular convulsive restlessness and struggling. If more

* This paper consists of a part of a chapter on Alcoholism, published in vol.
3 of the Nineteenth Century Practice .

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Treatment of Delirium Tremens.

alcohol is supplied more nervous energy is called forth
and there is more muscular excitement. Thus he is directly
enfeebled. Further, after alcohol freely administered there
is apt to be reaction, which reaction in this and other
diseases not unseldom perils the recovery of a worn-out and
collapsed patient.

There need be no fear of serious danger from the sudden
cessation of stimulants. Not many less than one hundred
thousand criminals and paupers are admitted into prisons or
workhouses every year in Britain. The bulk of these are
broken down inebriates, shattered by alcohol, yet their liquor
indulgence is forthwith cut off, not only without injury, but
with such remarkable benefit that they speedily regain
health and strength.

The first condition of cure, then, is complete abstention
from all intoxicating drinks.

Where any risk is feared, aromatic spirits of ammonia in
cinnamon water, aromatic powder in hot water, or hot water
itself, or some liquid preparation of beef, or hot milk, or
broth may be substituted with advantage.

It is true that even in some special institutions for the
treatment of inebriates, beer, stout, or an ardent spirit is em¬
ployed in small doses as a calmative; but through this quiet¬
ing is sometimes achieved for the moment by the anaesthetic
influence of alcohol on some individuals, it is never unaccom¬
panied (even when for the moment successful) with some
risk of subsequent damage.

The writer, therefore, strongly insists on the exclusion of
intoxicating liquors from the remedies with which we should
attempt to combat delirium tremens. In incipient slight at¬
tacks, soon after the premonitory symptoms have threatened
a seizure, a good dose of tincture of opium, an old-fashioned
but useful drug, will sometimes produce a sound, long sleep,
and avert the threatened attack.

With this exception, the less opiates are resorted to, the
better. The once common free administration of opium
with alcohol has been proved to be as unsafe and unreliable
in delirium tremens as it is in cholera.

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Treatment of Delirium Tremens. 29

Opium and morphine in substantial doses, by their lower¬
ing of vital energy, diminish the chances of recovery, apart
entirely from the risk of an overdose. It seems to be too
often left out of consideration that opium and morphine do
not counteract the deleterious narcotic action of alcohol, but
rather intensify it. That the risk of an overdose of opium is
real, the reports of many inquests testify. Fellow-students
of the writer, fairly moderate consumers of alcoholic intox¬
icants, have taken to opium or morphine to secure the sleep
which their arduous labors as physicians or scientific inves¬
tigators have robbed them of, and have been found dead
from the combined effects of the two narcotics; while
patients laboring under an attack of delirium tremens have
died from a sub-cutaneous injection of an opiate adminis¬
tered by the attendant physician.

Digitalis, in one dose of half an ounce of the tincture, fol¬
lowed, if necessary, by a second in a few hours and a third
of two drachms, has been highly recommended by Jones;
but the writer found it of no avail in averting a fatal issue in
one case, and its potency demands great caution in its ad¬
ministration.

Opium used to be largely employed in the endeavor to
induce sleep, which has been deemed by many to be the true
cure of the disease. But there are two kinds of sleep, one
sound, healthful, and natural, which if sufficiently prolonged
and if the patient awakes refreshed and calm therefrom, is
the principal curative process ; the other light, disturbed, fit¬
ful, short, and morbid, on coming out of which the patient
awakes unrefreshed and delirious or semi-delirious.

The sleep secured by opium and morphine seems usually
to be of the latter variety, and in many cases, by the subse¬
quent reactionary disturbance, to aggravate the nervous
tumult. These drugs require to be given in very large doses
to procure sleep in delirium tremens, and with such heroic
doses, in tissues already saturated with alcohol, deep and
prolonged coma may supervene, with a fatal issue accompa¬
nied often by profuse serous cerebral effusion. If an ordi-

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Treatment of Delirium Tiemene.

nary dose of either narcotic is given, the brain is only ex¬
cited and the general nervous perturbation intensified.

In one case of considerable gravity in a male intemperate
of the age of twenty-seven, the writer tried the experiment
of an evening dose of Dover’s powder one day, and on the
succeeding day an emetic dose of ipecac.

The sleep following the Dover’s powder was restless and
disturbed, the patient next morning when fully awake feel¬
ing parched and excited; while after the emetic of the pre¬
ceding evening he had a sound, restful, uninterrupted sleep
of at least five hours’ duration, and awoke comforted, rested,
and refreshed, with a steadier hand and quieter brain. A
good deal of these unfavorable effects may also arise from
cannabis, chloral, sulfonal, ether, chloroform, hyoscyamine,
and to a less extent from the bromides. Phenacetin in 8
to io grain doses for not more than two hourly repetitions is
less risky but unreliable. Chloral and sulfonal are depress¬
ing to the heart, besides, their lowering and disturbing
influences on brain and nerve function, the latter having in
some cases a strong and somewhat prolonged injurious
depressed excitant effect on the cerebellum, the patient
sometimes for days or weeks having a tendency to fall back¬
ward, and to walk with unsteady gait. Paraldehyde, trional,
and other hypnotics less dangerous than opium or "morphine,
are all more or less liable to be succeeded by reactionary
excitement after the artificially induced sleep is over. Potas¬
sium and sodium bromides, either alone or in combination
with chloral and henbane, have certainly at times proved
useful; though even when given by themselves, they have
often, to be effectual, to be given in such very large doses,
or in so'many repetitions of a dose (by the summation of
their cumulative influence more than equivalent to such an
unusually large dose) as seriously to depress vital function
and deprave the blood.

Even such comparatively innoxious antispasmodic drugs as
asafoetida and such harmless tonics as calumba and humulus,
though productive of no direct injurious effects through their

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Treatment of Delirium Tremens .

own action, and of no substantial reactionary after-symptoms,
are open to the objection that reliance on them is wasting
valuable time. The writer excludes such more potent tonics
as strychnine and its preparations as out of the question till
the delirium has ceased.

As delirium tremens is a direct product of alcoholic
poisoning, practically an acute disease produced by the
action of the poison on a nervous system so responsive to
such acute poisoning, either by reason of a preceding chronic
poisoning or of a susceptible nervous organization, rendered
so by a constitutional neurosis either inherited (as it gener¬
ally has been) or acquired under abnormal non-alcoholic
conditions ; as, in fact, the delirium is pimply a symptom of
active poisoning, the first indication of treatment is to elimi¬
nate the poison as rapidly as possible.

None of the medicinal substances just enumerated can
take an active part in this process of elimination, however
efficacious they may possibly be in other respects.

The poisoning process must be grappled with by speedily
freeing the system from the poison, and there are but three
easily available means of achieving this end.

So far as this alcohol elimination is concerned, the object
might be gained by diaphoresis in a Turkish hot-air bath,
but the depression and exhaustion consequent on a sojourn
long enough to be effectual, as well as the impossibility of
securing a bath with adequate attendance, in most cases,
contribute to render this plan as a rule impracticable. Even
in a hospital furnished with an ample Turkish bath, expen¬
sive attendance would be needed, the temporary dwellers in
the sutatorium being bodily unrestrained by bedclothing, with
the additional risk of the deliriates injuring themselves in
their convulsions and struggles. The perspiration, which is
the only efficient method of securing the necessary elimina¬
tion of the poison, might be secured by the wrapping of the
patient in a wet pack, but this is liable to the special objec¬
tion that, particularly in grave cases, the close restraint of
the contorted sufferer in a properly fitting pack would
Vol. XVIII.—s

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32 Treatment of Delirium Tremens .

heighten the nervous excitement and cerebral pressure,
everyone knowing this to be the effect of forcibly restraining
violent involuntary muscular action.

In light forms of delirium tremens, both the Turkish bath
and the wet pack are sometimes of service where they can
be conveniently applied, and the writer will later on speak of
their great usefulness in certain phases of chronic and sub¬
acute alcoholism ; but in violent cases of delirium tremens
he cannot recommend either, in ordinary practice.

In addition to rapidly clearing the alcohol out of the
body, it is of the highest importance to conserve the patient’s
strength. To restrain his muscular contortions would be
more quickly thereby to exhaust his vital energy, which,
especially in those who have had repeated attacks and have
not been abstemious in the intervals, is not generally so
abundant as to warrant any preventable loss of it.

This preservation of nerve force is best accomplished by
allowing the muscular movements to be as untrammeled as
possible. There are two ways for providing for this. One
is by shutting up the delirious patient in a padded room,
where he can have nothing to injure himself with and cannot
hurt himself, even if he dash himself in blind fury against
the padded walls.

This is a procedure which is rarely obtainable, though by
the favor of the master of a London workhouse the writer
was once enabled to employ it in the case of a publican, who
could not properly be controlled or fed in his public house
by five men, and whose unruliness and cries were seriously
detrimental to the trade carried on in the shop beneath his
bedroom.

The man received no medicine, milk and coffee being
handed to him through an aperture in the door padded in
the interior, but in some three days he exhausted himself and
fell into a profound and long sleep, from which time he
steadily and thoroughly recovered.

This excellent provision of a padded room being, how¬
ever, rarely within our reach, must be regarded as in gene-

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Treatment of Delirium Tremens .

ral practice also impracticable. One is therefore driven to
find a medicine which, while operating, as soon as may be, to
get rid of the accumulation of alcohol in the system, would
not by the depression of narcotization oh reactionary excite¬
ment weaken the vis medicatrix, in which latter really lies
the potency of cure.

All this the writer believes he has found in the innocent
yet powerful liquor ammonii acetatis, which in addition seems
(either by its antifebrile properties or by some unknown
chemical action on the alcohol saturated tissues) to exert a
specially favorable influence on the rapidity and completeness
of the elimination.

The usefulness of this drug in alcoholism is not limited
to delirium tremens; but in delirium tremens it has appeared
to combine all the advantages of the cooling and calming
emetic treatment by ipecacuanha, with, by the characteristic
profuse perspiration which it causes, the best qualities of the
wet pack and hot-air bath.

Withal, there being neither chemical nor muscular re¬
straint, the restless sufferer's already lessened nerve force
(lessened by the disease) is not further drawn upon to com¬
bat the depression occasioned by opiates or other narcotism,
and the nervous exhaustion from the excitation aroused bv
the physical restraint (envelopment in a close packing of
sheet and bedclothes, as in a straight-jacket) of turbulent
and inco-ordinate muscular contractions.

Since relying mainly upon the acetate of ammonia, the
writer has had much less trouble with cases of delirium
tremens, a great deal less anxiety from serious compli¬
cations (which formerly chiefly arose from the after-effects
of opiate, chloral, and bromide remedies), and a much larger
percentage of good recoveries. Of course, care must be
taken to have sufficient attendance to guard the patient from
harm. This is a point very often of vital importance. If in
delirium the vigilance is relaxed, there may be a sudden ter¬
mination of the case.

Though, usually, alcoholic deliriates in attacks of delirium

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Treatment of Delirium Tremens .

tremens are fairly easily manageable, suicide may be
attempted in almost the momentary absence of a nurse. The
maximum extent of freedom compatible with safety is at¬
tained by the patient being kept in bed. With a little tact,
an intelligent attendant can exercise considerable control
over the excited patient by pressing down on the patient
near and over the knees outside the blankets. This allows
free play for practically all needed involuntary muscular
movement. The patient is thus allowed to exhaust himself
by his continuous muscular efforts, till the true restorative
state of natural sleep overtakes him through sheer weariness.
There is nothing so valuable here as the sound, wholesome
sleep of fatigue; in character and effects so opposite the
unwholesome, disturbed, and disturbing sleep procured arti¬
ficially by narcotics.

In all that has just been stated about the treatment of
delirium tremens, and this is equally true in other diseases,
it should ever be borne in mind that exceptional cases may
occur which may require alcohol or other remedies not here
referred to.

The writer is ready, for example, to administer alcohol at
any time when it appears to be called for, but he has never
yeF*seen a case of delirium tremens in which he considered
this remedy was desirable.

We give place to a long clinical paper to make
the value of trional which has came into much
hence lately. Schieffelin & Co. are the American
for this drug.

known

promi-

agents

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Report of the Mass . Hospital for Dipsomaniacs. 35

REPORT OF THE MASSACHUSETTS HOSPITAL
FOR DIPSOMANIACS AND INEBRIATES AT
FOXBOROUGH.

The following extracts from the report of this hospital
under the charge of Dr. Hutchinson will be of great interest
to our readers.

There have been 212 admissions during this year, 59 more
than during the previous one. The daily average number
resident in the hospital was 125.14.

Few subjects are receiving more general and persistent
consideration than that of inebriety, and there is none upon
which more varied and opposing views are maintained. The
term “inebriety” is inexact, and thus far no clear and suf¬
ficient definition of it has been given. Still it is accepted
as the distinctive name of a true disease, a phase of insanity,
characterized by an intense, imperative, irresistible craving
for the soothing effect of some narcotic poison, notably
alcohol. It is distinguished as a disease, not as a habit. As
a disease it has its history, causes, and symptoms, and is
subject to pathological laws as are other diseases. In the
words of the American Association for the Cure of Inebri¬
ates, it is “ a disease that is curable in the same sense that
other diseases are, its primary cause being a constitutional
susceptibility to the alcoholic impression, which may be in¬
herited or acquired.”

It does not, as an organism, enter the system from with¬
out, but arises from within, and exists as a change of structure
or function, or both. Apparently no organ or tissue escapes.
There are irregularities in the functional activity of the vari¬
ous organs; there is impairment of muscular movement, even
paralysis; also neuritis, with its attendant pains, frequently
called “rheumatic pains.” When fully developed, it mani¬
fests such symptoms as are associated with hardening of the

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36 Report of the Mass . Hospital for Dipsomaniacs

tissues and fatty degeneration. The most characteristic of
them, diminished will-power, blunted moral perception, and
impaired cerebration, point to the brain. They indicate a
state of dementia which frequently can be recognized long
before it is sufficiently pronounced to justify a certificate of
insanity.

The careful observations and studies already made of the
condition of the inebriate, the subject of chronic alcoholic
poisoning, have made it apparent that this disease is very
largely dependent upon inborn tendencies, or heredity, and
upon surrounding conditions and influences, or environment ;
that it is frequently dependent upon physical conditions and
causes with which the substance alcohol has nothing to do;
that where there are no predisposing or exciting causes, it
may be originated by the indiscreet or inconsiderate use of
alcohol itself.

The inebriate, as he is presented for care and treatment,
is usually shattered by years of alcoholic indulgence and dis¬
sipation. Not infrequently he is further weakened by some
associated neurosis, or by some organic or constitutional dis¬
ease. It is not reasonable to suppose or expect that under
such circumstances he can be restored to health in a few
weeks by the use of any one drug, or combination of drugs,
alone. Other agencies must be employed,— complete ces¬
sation from the use of alcohol, restraint and control of the
person for a time, even for a long time, rest, freedom from
worries, baths and systematic exercise, occupation, regularity
in habits, diets, and good hygienic surroundings. Most per¬
sons must seek the protection and care of a hospital, for they
are too deficient in will-power to be controlled by personal
appeal, pledge, or fear of financial or social ruin.

There is no short cut by which the disease can be checked
and the diseased tissues restored to their normal condition.
It is necessary to follow the same general course as in the
treatment of other diseases, particularly those affecting the
nervous system. Until the exact pathology of the disease
and the true physiological action of alcohol are demonstrated,

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and Inebriates at Foxborough.

it will be necessary to look to the inferences and results of
experience for guidance in its treatment.

It may be of some interest to indicate what is sought to
be done in the care and treatment of those committed to this
hospital. By the statute law governing commitment to and
detention in the hospital, provision is made for one of the
chief factors in treatment,— time, or prolonged residence in
the hospital. Time is necessary, compelling the non-use of
alcohol, affording an opportunity for nature to restore the
diseased tissues to their normal condition, and also for the
sustained use of drugs, baths, exercise, and other remedial
agencies. Under the law, a man, when committed, can be
detained for two years. The trustees are given discretion¬
ary power for earlier discharge, which discharge is not full or
final, but conditional, or leave of absence. When so dis¬
charged, any person violating the conditions of his release
and resuming his drinking habits may be returned to the
hospital and there detained during the unexpired portion of
the two years for which his commitment papers are valid.
According to the rules established by the board, each person
is allowed to go from the hospital on leave of absence at the
end of six calendar months, provided he has met all require¬
ments as to the taking of medicines, occupation, and attend¬
ance upon the classes in physical training.

When received at the hospital each person is bathed and
then examined for injuries or anything else unusual. He is
then placed in a room, where he remains in seclusion for
some days, to preserve his strength, if much debilitated or in
a state of delirium. The use of alcohol in any form is
stopped at once. While in a state of delirium he has an at¬
tendant constantly near him, both night and day. When
otherwise seriously sick the same watch is maintained. Ap¬
propriate treatment is directed to the relief of the conditions
resulting from the use of alcohol, and also any complicating
disease.

At a suitable time each one is required to attend regu¬
larly a class in physical training. About one quarter part are

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38 Report of the Mass. Hospital for Dipsomaniacs

excused for some positive incapacity. The classes in phys¬
ical training are under the direction of one who has been
specially educated for such work. His services are given
during five half-days of each week. At the close of each
exercise each class receives, at the hand of the instructor
himself, a carefully tempered bath, a spray bath, which
cleanses the body of all exudations, stimulates the nervous
system and the subcutaneous circulation. As the patients
present themselves for the training, they show faulty atti¬
tudes, weakened organs of circulation and respiration, im¬
perfect muscular co-ordination, comparative inability to
concentrate and apply their mind, slow response to mental
stimuli, diminished will-power. It has not been sought to
train athletes for the performance of special acts, but to
bring about a healthy action of heart, lungs, and mind, and
more perfect co-ordination of nerves and muscles, a proper
performance of the other bodily functions, to form habits of
order, application, and purpose ; most of all to increase the
power of the will in controlling, through its organs, the
central nervous system, all functions, movements, and desires
of the body. This end is sought through a series of move¬
ments so arranged and executed as to bring all parts of the
system under the influence of the will, and to strengthen the
will through the frequent and well-directed use of it.

To afford the instructor a thorough knowledge of each
patient, to enable him to better understand his condition,
his weaknesses, and needs, and in turn to more intelligently
regulate the amount and character of the exercise he is to
receive, an examination is made. Such matters as height,
weight, lung capacity, state of nutrition, etc., are noticed.
By means of special machines, tracings are taken upon paper
of the outline of the chest in a vertical section from front to
back, while in a state of rest and also while in the state of
full inspiration and of full expiration. Similar tracings are
made of a horizontal section of the chest. Another tracing
is made showing the line of the spinal column and any lateral
curvature, if present. Another such set of tracings is made

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and Inebriates at Foxborough.

just before the patient goes from the hospital. By com¬
paring the two sets, a ready estimate of the improvement
secured is made. By the original diagrams, particularly
when compared with those of fellow-patients, each one is
shown his defects, so that he will the more willingly and
intelligently assist in remedying them. Each month what
is called the strength test is made. This consists in ascer¬
taining the height, weight, lung capacity, strength of back,
chest, legs, and forearms by means of special instruments.
These items &re brought into relation to each other, and
projected on a chart as a diagram. As a record, and for the
purposes of comparison, each patient has a chart devoted to
him, upon which his line or diagram for each month is pro¬
jected. These charts act as a safeguard to the instructor.
They show the exact standing of each patient, and give him
a chance to modify the treatment for such as have not made
satisfactory progress. By explaining his chart to each patient
he can see and know how much progress he has made, or to
what extent his defects have been remedied ; and it may be
hoped that he will be stimulated to more earnest co-operation
and effort.

The patients are also placed upon parole within the limits
of a certain portion of the hospital grounds, and have this
freedom from breakfast time to that of supper. When given
parole they are at the same time assigned to some task.
Thus they assist in the kitchen, dining-rooms, laundry,
boiler-house, barns, in the work upon the farm, in painting
and general repairs. There is also a broom shop, which
affords employment for some all the time and for many
during the winter season.

During the past winter the patients have provided them¬
selves with an entertainment nearly every week. These
have been arranged and conducted by a committee chosen
for each evening, by their own action, from among their own
number. They have always relied upon the talent to be
found among themselves and employes. Occasionally kind
friends have assisted, coming from the village.

Vol. XVIII.— 6

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40 Report of the Mass . Hospital for Dipsomaniacs

Another great need in connection with the classes in
physical training is better and increased facilities for bath¬
ing. As it is at the present time, the class is huddled to¬
gether in a small room under a waterproof canopy, touching
elbows, while receiving the needed bath administered
through the spray nozzle of an ordinary garden sprinkler.
A few of the men have objected to attending the classes
because of the lack of privacy in connection with the bath.

Mention is made below of some of the men who have been
longest away from the hospital, and who are still looked
upon as doing well, or abstinent. They serve to indicate the
good accomplished under adverse, even seemingly hopeless
circumstances. Many who are admitted are evidently hope¬
less from the first. During the year seventeen have been
transferred to a hospital for the insane. Many others are
recognized as very close to the line, if not actually within
the limits, of insanity. Others are subject to such gross
physical degeneration as to preclude any hope of lasting ben¬
efit.

Stone cutter, sixty years old, widower ; has been drink¬
ing for forty years ; to excess during the past twenty, as of¬
ten as every two months. Has no known heredity or ex¬
citing cause. Has no known associated habit. Has been
much more intemperate since the death of his wife, sixteen
years ago. At time of commitment was tremulous, irrita¬
ble and somewhat confused and debilitated. He was under
treatment about six months. He has been absent from
the hospital twenty-three months, and according to the
statement of his children he is doing all right, is working
regularly, is as they would wish him, is happy with them and
they with him, contrary to what has been during the past
twenty years. He has not taken anything intoxicating
but once, in small quantity, and that was associated with
July 4th.

Professional man, forty-three years old, married; has
drank for years; uses Jamaica ginger as freely as he does
liquor. For six weeks just prior to commitment he con-

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and Inebriates at Foxborough.

sumed large quantities of liquor, also of Jamaica ginger.
At entrance appeared to be verging upon delirium tremens.
His father used liquor. No known exciting cause. His in¬
dulgence was solitary. During this last spell he has imag¬
ined that his wife was intending to poison him, and he be¬
came very ugly towards her. At entrance he was much de¬
bilitated, tremulous, and his stomach was much disordered.
Had an alcoholic fit four days after entrance. Says he had a
similar fit about thirteen years ago. Was in the hospital
about six months. Has b$en at home twenty months, and
from reliable sources it is known that he has continued absti¬
nent and has attended to his business regularly.

Laborer, thirty-two years old, unmarried; duration of
drinking habits unknown. His father was a heavy drinker.
He has been known to the committing physicians as a con¬
firmed inebriate, who wandered about at night searching for
some imaginary thing, and was a nuisance to those around
him. Had no known associated habit. At time of admis¬
sion he was extremely weak, but* not intoxicated. At end of
ten days he began to rally, and improved rapidly. Was in
the hospital about six months, and his improvement was very
pronounced. Has been at home a little more than nineteen
months, and is known to have worked regularly and to have
been abstinent.

Carpenter, forty years old, married ; has drank for twenty-
five years, or since he was fifteen years old ; has always drank
immoderately, but much worse since his head was cut, two
years ago, taking his liquor away from home. His father
and mother both used liquor to excess. All his relatives are
or were people of weak constitution. When not in liquor he
thinks well of his family, but when in liquor he is ugly and
abusive, and for that reason his wife has once left him. An
employer has discharged him because of violence threatened.
He was in the hospital six months. Has been home eighteen
months. From reliable sources it is known that he has
worked regularly, has been what he should be to his family,
and also abstinent.

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42 Report of the Mass . Hospital for Dipsomaniacs

Bartender, thirty-eight years old, married; has drank
during all his married life of five years, how much longer is
not known. Has drank immoderately during the last year.
No known heredity. Entered the hospital in a state of de¬
lirium tremens ; was entirely incoherent and very tremulous.
Required camisole during the first twenty-four hours, to pre¬
vent self-injury. Became coherent on the third day. He was
in the hospital a few days less than six months. Went home
in a very much improved physical condition. After an ab¬
sence of nineteen months it is known that he works regu¬
larly and is abstinent.

Salesman, twenty-eight years old, married ; has drank for
seven years ; has also used choral and absinthe. His father
and all male relatives on his father's side have used liquor.
His maternal aunt is insane. During the year preceding his
commitment he used whisky or brandy daily in large quan¬
tities, and developed marked chronic alcoholic poisoning.
He has had eleptiform seizures undoubtedly due to alcohol- 1
ism. At such times he was violent to persons and destruc¬
tive to things, requiring vigorous restraint. At entrance was
sober, but tremulous and much debilitated from recent drink¬
ing. He had a severe fit the same evening. He was in the
hospital about six months. Has been absent from the hospital
eighteen months, and according to good authority he has
been constant at work and abstinent in habit.

Clerk, thirty-five years old, unmarried; has drank during
eight years, and to excess during the last three. Hereditary
or exciting causes unknown. He always began with beer,
socially, and ended with whisky. He has had treatment a
number of times in a private institution. At entrance quite
tremulous, stomach much disturbed, heart's action irregular,
and had bromide eruption over body. Has been out of hos¬
pital twenty-three months, and has continued abstinent and
industrious. Recently his father wrote: “ He is one of the

best improved young men in-, in a good position. If

you saw him I think that you would not know him, the im¬
provement is so great for the better. He has no use for
liquor now.”

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and Inebriates at Foxborough . 43

Salesman, forty-four years old, unmarried ; presented him¬
self for examination and asked for his commitment. Has
drank during twenty-three years, and to excess during the
last eight or nine. Admits being in house of correction
about four years ago, and also in the Massachusetts Re¬
formatory about a year for inebriety. His drinking habits
quite constant of late years. He bore evidence of continued
chronic alcoholism. Eight months prior to admission was
much troubled with diarrhoea, for which he took laudanum
and rhubarb; then laudanum alone; became frightened at
the laudanum, and took to whisky. Said he had been drunk
every day for six months. After being in the hospital three
months he ran away, remaining out one month, when he was
returned to the hospital. He then remained about seven
months. Has now been out of hospital seventeen months, and
during that time has been seen frequently by people from the
hospital; at such times always was sober. He is now man¬
aging a good business. His friends claim that he has at all
times been abstinent.

Angina Pectoris Due to Tobacco. — Professor Po-
tain points out ( m Journal de MIdecine de Paris , October 6,
1895) certain peculiarities enabling the physician to dfSgaose
the angina pectoris caused by the excessive use of tobacco.
In true angina pectoris from a corony lesion, the attack is due
to increased work of the heart; the pain is of a tearing,
burning character, and is substernal. In tobacco-angina the
attack is spontaneous, without any effort on the part of the
heart, and lasts several hours. The pain is often substernal,
but also frequently praecordial; it is as intense as in true an¬
gina pectoris, but there is a feeling of dilatation. This rule,
although not absolute, will be found to apply in the majority
of cases, and it will also be observed that whereas in true
angina pectoris the least movement will increase the attack,
that due to tobacco is in nowise influenced by movement.

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44 Annual Report of Walnut Lodge Hospital.

ANNUAL REPORT OF WALNUT LODGE HOS¬
PITAL, HARTFORD, CONN.

The work of this hospital during the year 1895 continues
to be of the same interest as of former years.

The grouping and study of cases that are practically un¬
known have always a fascination that deepens as the real facts
multiply. In a small institution where each case is made
the subject of exhaustive study, some idea of the laws of
physiological and psychological growth and decay is
obtained. Opportunities occur of verifying facts and
theories more difficult to utilize in a larger hospital. Special
means of treatment which can be individualized and applied
to meet the particular care are always practical where only a
few persons are treated.

The special object, as heretofore, has been to give each
case the best possible facilities for restoration and to concen¬
trate the most practical means and methods which the his¬
tory of the case demanded.

The records of the year show that fifty-two cases were
admitted for treatment; this, with the eight cases in the
hospital at the beginning of the year, makes sixty cases in
all under treatment in 1895. Forty-four of these cases were
discharged and left the hospital.

The following indicates a general classification of the
character of the cases :

Periodical Inebriates, ..... 23

Continuous Inebriates, - - - • - - 10

Dipsomaniacs, -------- 4

Opium Inebriety, - - - - - - 9

Cocaine Inebriety, 2

Chloral, Ether, Ginger, and other Inebriates, 3

Complex cases using any narcotics at hand, .... 7

Exhaustion, spirits used as remedies, ..... 2

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Annual Report of Walnut Lodge Hospital. 45

This general grouping is clinical and describes cases by
the most prominent symptoms apparent. Many of the
chloral, ether, and other drug-takers, may at times use
spirits, opium, and cocaine. But for some unknown reason
abandon them soon and depend on some specific drugs, such
as choral, ginger, ether, or allied narcotics. These cases
are repeaters and are often treated in different asylums for
different drug addictions. The complex cases are of the
same class, except they do not appear to have any special
drug addiction, but use any one most convenient. It is un¬
fortunate that any cases should occur in which spirits are
used by advice as voluntary for its supposed medicinal effect.
In the two cases under treatment, both the patient and
friends became alarmed at the necessity for the use of
spirits and the treatment was followed by the most favorable
results. The cocaine cases were the usual complex examples
where other narcotics had been used before. Physicians
seem to be the most exposed to this form of drug addiction
and not unfrequently the most incurable.

In a study of the causes the same class of facts have
become more prominent.

The following table gives an outline of these facts:

Heredity direct, - - - - 19 Traumatism, - - - 6

Heredity indirect, - - - 12 Exhaustion,.5

Heredity collateral, - - - 11 Environment and contagion, - 7

Direct heredity is used to describe cases where the drink
craze or symptom was prominent in the parents. The
indirect heredity describes cases where inebriety of some
ancestor noted in the grandparents, and the immediate
ancestors were free from this disease, although exhibiting
defects and degenerations.

In the collateral heredities various neurotic disorders
occurred in the ancestors, of which inebriety, epilepsy,
hysteria, paranoia, consumption, and other brain and nerve
disorders are common.

Traumatism or injuries are no doubt responsible for
many cases that are unknown at present. Shocks and brain

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4 6 Annual Report of Walnut Lodge Hospital.

strains are not only obscure but profound in their effects
and become the starting point of serious lesions of nerve and
brain cells. Exhaustion includes a great variety of condi¬
tions that are noted by anaemia, cell and tissue starvation.

The influence of contagion and surrounding is always
prominent in developing latent defects and tendencies to
certain diseased states.

Of itself alone it appears to be an important factor, but it
acts both as an active cause and as a symptom of other
states. In three of the cases under treatment some defect
of the brain centers existed from birth, probably retarded
development, and the persons exhibited an unusual suscepti¬
bility to surroundings. They became early inebriates from
contagion, but responded to changed surroundings and
society hopefully. The following tables relate to some
general statistical facts:

Age of Persons under Treatment .

From 20 to 30 years o* age, - - 10 From 50 to 60 years of age,-

From 30 to 40 years of age, - - 24 From 60 to 65 years of age, -

From 40 to 50 years of age, - - 18

Social Condition.

Married and living with wife, - 36 Widowers, -
Married and separated from wife, 2 Single, -

Physicians,
Lawyers,
Farmers, -
Merchants,
Clerks, -
Manufacturers,
Druggist,
Lumbermen, -
Drummers,
Speculators, -
Engineers,
Barber, -
Students,

Occupations.

- 7 Spirit dealers,

- 4 Broker, -

- 3 Mechanics,

- 2 Soldier, -

- 6 Bankers,

- 4 No occupation,

- 1

- 2 WOMEN.

- 2

- 4 Housewives, -

- 3 Teacher, -

• 1 Physicians,

- 2 No occupation,

l 7

- 2

- 3

- 1

- 2

- 3

- 1

- 2

- 1

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Annual Report of Walnut Lodge Hospital . 47

Duration of the Inebriety .

From 5 to 10 years, ... 8 From 15 to 20 years, - - - 15

From 10 to 15 years, * - -26 Over 20 years, - - - - 11

Education .

Collegiate,.19 Academic,.20

University,.10 Common school, - - • - 11

Former Treatment in other Hospitals.

Been treated at Keeley Institutes, - - - - - - 31

Treated by other Gold Cure Specifics, ..... 10

Treated at other hospitals, ------- 7

Never treated before, - - - - - - 12

The relapsed cases from the use of specifics are increas¬
ing, and the same class of symptoms, resembling acute in¬
sanity with hallucinations are common. The experience of
other asylums are confirmed in the difficulties of treatment
and the extreme prostration manifested by these cases. The
delusion that the cure is effected when the taste for spirits
dies out, and that some heroic remedies can be given to
change and restore the brain to health in a brief time, is
very prominent in most of these cases.

The Results of Treatment .

Recovered,.23 Improved,.13

Unimproved, 6

These figures are a fair approximation of the present
results. The unimproved are those who relapse soon after
leaving and who manifest, during treatment, a continuous
desire to procure spirits. They are practically insane and
possessed with a dominant idea of using spirits without any
particular motive. Every possible physical ill suggests
spirits and every condition of life, real or anticipated,
demands the same. The control of this impulse by drugs is
only another form of restraint, that is temporary, and fails
because it does not reach back to the real causes. Many of
these cases recover permanently, usually dependent on un¬
known causes and physiological conditions.

Vol. XVIII.— 7

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48 Annual Report of Walnut Lodge Hospital .

This gives encouragement to continuous effort, even in
the most hopeless cases, especially hygienic and constitu¬
tional measures, which encourage physiological changes in
the entire body.

Of the class marked recovered, a knowledge of the
causes of the inebriety has suggested methods of treatment
that would remove such causes and point out conditions of
living that would prevent relapse in the future. Many of
these cases may be considered cured in the broadest mean¬
ing of that word. The results of exact physiological
hygienic and asylum treatment of all these cases is not only
helpful and hopeful, but brings the reasonable promise of
cure in exact proportion to a knowledge of the causes and
their removal, together with the building up and restoration
of the entire organism.

That inebriety is curable is an established fact. To what
extent we do not know, nor are we yet familiar with all the
various means and appliances suitable for each case.

One of the most serious obstacles which all institutions
encounter is the unreasonable criticism of the public.

The delusions of patients are accepted as facts, and the
work is regarded as empiric and based on the lowest motives,
of which taking advantage of the weakness and emergency
of patients is prominent.

The laws do not give asylums power to hold cases long
enough to secure reasonable promise of cure and the sus¬
picions of the public magnify the failures, and those who are
permanently restored disappear and make every effort to
conceal the fact of treatment.

Yet, notwithstanding all the various obstacles, the growth
of asylum treatment of inebriates has been rapidly increasing.

Walnut Lodge Hospital has followed a uniform contin¬
uous course of progressive experimental work; especially in
seeking to obtain a clear history of each case and the proper
means and remedial measures best suited for restoration.

It has been repeatedly proven by experience, that special
individualized personal treatment, based on a knowledge of

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Annual Report of Walnut Lodge Hospital ’ 49

the facts of the history, gives the best promise of success in
recovery.

This can be accomplished in small hospitals and by per¬
sons who manifest a practical scientific interest in both the
pathological and psychological symptoms, fully realizing that
recovery depends on the use of every means that can possibly
build up and restore the brain and body.

The publication of the Journal of Inebriety, now in its
eighteenth year at this hospital, brings us in a very close
relationship to the literature and scientific studies of this
subject from all over the world.

We are thus able to compare our work and utilize and
test the experience of others to a greater extent than usual.
Many of the conclusions from studies here are published in
this Journal, which, together with the experience of other
asylums, form a valuable addition to a knowledge of the
subject.

The results of the year's experience is the accumulation
of facts confirming the conclusions which were asserted
years ago with so much confidence “that inebriety is a
disease and curable as other diseases are.”

Starting from this point the great questions awaiting
solution are, To what extent are these cases curable ? What
are the laws which govern the origin, progress, and termina¬
tion of these drug neurotics ? Also, what are the means and
remedial measures most valuable for this purpose ? Towards
the solution of these questions we have been able to add
considerable evidence.

The narcotic neurotic is still a mystery. The term
inebriate is used to describe a class of neurotics whose
disorders are only faintly outlined by the most advanced
studies. Each hospital and asylum is slowly and with great
difficulty pushing on into this new land. In every direction
new facts, new laws, and new forces appear. The work of
each year widens and enlarges the next and the failures and
successes of any particular asylum really broadens the road
and gives greater capacity for a larger work. The men and

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Annual Report of Walnut Lodge Hospital,

women who have been restored and helped at Walnut Lodge
in the year past have been literally object lessons and mile
posts, to indicate the direction of the movement that will
literally stamp out and neutralize in the future not only the
drink evil but many of the forces which manifest themselves
in this way.

It is impossible, in a brief report, to convey more than a
general impression of the work at this hospital. The kindly
sympathy and interest by the members of our board have
helped to make the work more effectual and has elicited our
deepest gratitude.

The possibility of still further helping on the work by
contributions of books to our library has created a lively
interest among many of our friends which we hope may ex¬
tend to others.

Tea Cigarettes. — The Lyon Medical for December ist
says that fashionable English ladies are no longer content to
drink tea, but that they smoke it at their five o’clock teas.
A lady who is very well known always has tea cigarettes
passed around after dinner. Another spends nearly two
pounds sterling a week in order to gratify her taste for tea
cigarettes, and three celebrated actresses have given tea¬
smoking parties several times. In Kensington a number of
literary ladies have organized a club for this same purpose.
The habit has spread so elsewhere that tobacco merchants
are offering packages of tea cigarettes to the public.

The surgeon-general now assures us, and furnishes sta¬
tistics to prove, that inebriety is on the decrease. In 1890
no less than seventeen posts had more than ten per cent, of
their average number under medical care for drunkenness ;
in 1891, eleven posts; in 1892, ten ; in 1893, seven, and in
1894, four. These figures are hopeful, and warrant the belief
that in the near future delirium tremens will form no part of
the unofficial tactics of our standing army.

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The Late Dr . Albert Day .

THE LATE DR. ALBERT DAY. — A BIOGRAPHI¬
CAL SKETCH.

By T. D. Crothers, M.D.

Our readers will recall the many papers and selections
from the writings of Dr. Day which have appeared in the
Journal almost from the beginningof its publication. These
papers were always noted for a breadth of observation and
practical recognition of all the conditions present. The ine¬
briate to him was diseased and degenerate in all directions,
physically, mentally, and morally.

His writings always attracted more attention among tem¬
perance philanthropists and reformers, and were very largely
quoted, and had a wide influence in correcting popular errors
of the day.

Dr. Day was born in Wells, Maine, in October, 1812, and
died at Melrose Highlands, Mass., April 27, 1894. The
death of his father in early life forced him out into the world
dependent upon his own resources. After mastering a trade,
he determined to secure an education, which was accom¬
plished by studying nights with great persistency and energy.
He finally graduated from the Harvard Medical School and
entered upon asylum work for inebriates.

He was early attracted to reform measures for inebriates,
and was identified with the Washingtonian movements of
1840. In 1856 he was a member of the Massachusetts Leg¬
islature, and introduced measures which finally culminated in
the establishment of a home for inebriates. After varied re¬
form efforts he became superintendent of the Washingtonian
Home at Boston, organized in 1857. This was the first asy¬
lum that was opened for inebriates in the world. Other in¬
stitutions were in process of organization, and the idea of dis¬
ease and physical care and treatment were maintained and
disputed with energy and earnestness.

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The Late Dr. Albert Day .

The Washingtonian Home began as a lodging house, and
by slow beginnings and halting progress, grew up to* an asy¬
lum, in which the idea of physical care and treatment became
prominent. Dr. Day followed, with good judgment and clear
sense, making prominent the moral side to keep the confi¬
dence of the friends and patients of the asylum, and at the
same time urging the physical necessities to support the
moral. The power of an idea, and the force of moral conta¬
gion was pressed daily as a remedy, and for years this was
ostensibly the special treatment of this asylum. In reality it
was only the stage setting, the play and actors were very dif¬
ferent.

After enthusiastic appeals to sign the pledge and trust to^
faith and prayer, Dr. Day would urge in private a material¬
istic course of conduct that was startling to the patient, who
supposed his malady was a spiritual one. To many persons
this was very strange; after making one side prominent in
public, in private he attached little importance to it. Evi¬
dently Dr. Day had a very clear conception of the power of
the mind over the body, and its peculiar potency in this class,
and realized that a combination of the two methods of treat¬
ment were essential.

In 1867 Dr. Day was called to preside over the fated asy¬
lum at Binghamton, N. Y. Three years later he resigned
and opened a private home at Greenwood, Mass. This was
burned down some years after, and he was recalled to the
charge of the Washingtonian Home, where he remained until
1893, when he resigned from ill health, and moved to Melrose
Highlands, Mass.

He was actively engaged in asylum work for inebriates
thirty-seven years, and some six years before he was man¬
ager and director of an inebriate lodging house and asylum for
the temporary relief of drunken men found homeless on the
street. Altogether his active life in this special field was over
forty years. More than ten years before he had been a very
active temperance man and was always engaged in efforts to
help the inebriate and educate the public to realize the dan-

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The Late Dr. Albert Day. 53

gerfrom the use of spirits. At his death he was the oldest
pioneer worker in this new field. He had no doubt seen
more inebriates and treated them medically than any other
person. Dr. Day was one of the original members of the
American Association for the Study and Cure of Inebriates
which was organized in 1870, and at his death he was presi¬
dent.

In 1888, a reception and dinner was given to Dr. Day on
the thirtieth anniversary of the Washingtonian Home, an ac¬
count of which has been published in this Journal.

Dr. Day was not considered a great scholar or bold pio¬
neer leader far in advance of his day and generation, but he
was eminently a wise, prudent man, who sought rather to
give shape and direction to events of the present than to lead
beyond. While not antagonizing the theories of the day in
any harsh way, he turned them into new channels and roads,
and pointed out new and wider meanings to the foolish dog¬
matism of his cotemporaries. This was done in such an
adroit way as to escape all criticism. On the platform as a
public speaker, in his contact with patients, and everywhere,
he seemed to accept all the moral teachings of others, and
added to them the most pronounced materialistic rational
means of treatment, which were accepted without controversy.
He was an optimist who realized the limitations of theories,
and who never lost faith in the final triumph of the truth.
The most of his life was an exasperating struggle with theo¬
rists, and delusions of half-vice and half-disease. The public
demanded that he should point out remedies to reach and
control the paranoic inebriates, and teach the only proper
means and methods of cure. Wild storms of harsh criticism
were always about the asylum, and the pulpit and press and
philanthropists and good men and women were always ready
to condemn. A new work opposed to the common sentiment
of the day must pass through the fires of persecution, and
Dr. Day and the Washingtonian Home were no exceptions.

Dr. Day was clearly a great captain guiding a ship
freighted with new facts and new truths down through the

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The Late Dr. Albert Day.

most difficult narrows to the open waters beyond. His gen¬
ial, sunny faith never lost sight of the highlands before him.
Thus year after year he struggled on until he saw the final
acceptance and endorsement of the truths which had been so
violently opposed in the early years of his work.

The yearly reports of the Washingtonian Home contain a
very significant history of the growth and progress of the dis¬
ease theory, and the struggles to keep just ahead of public
sentiment and not startle the friends of the asylum. The
asylum was an infant dependent on a variety of widely differ¬
ing theories; the acceptance of any one to the exclusion of
the other would have been its ruin. It required rare tact and
judgment to follow a medium course, and avoid the threat¬
ened dangers. Dr. Day could not have succeeded had he
been indiscreet and impulsive, or failed in any way to recog¬
nize the conditions about him, and act upon them wisely.
He could not have accomplished more by original research
or elaborate investigation. All his tact and energies were
needed to formulate and organize the half-theories into
working principles, good for the present and valuable as step¬
ping-stones for the future.

Later, when he was beyond this point of preliminary
work, he realized that more might have been done from elab¬
orate studies in this field, but he saw that it was only by the
long era of preparation that the ground had been cleared
away for other and more scientific work.

Dr. Day's real work to the cause of science and the de¬
velopment of the fact of disease in inebriety will appear more
clearly as the years roll on and the subject is better under¬
stood. He, more than all his cotemporaries, gave promi¬
nence to the power of ideas, and the mental force of sugges¬
tion. He taught that ideas, coupled with physical forces,
were all powerful. This is a realm which has not yet been
opened. The appeals and prayers and pledges, and the physi¬
cal means used continuously, were forces that sent many poor
unfortunate inebriates back to health again. Dr. Day was a
cheerful, sunny man, kind-hearted, tender in his sympathies,

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The Late Dr\ Albert Day .

and warmly attached to those who were struggling to do
right. He was a close reader of current events, and followed
with great interest all the changes of science and social life.
He took an active part in church and masonic matters, and
stood high in the latter order.

After a long life of active, arduous work, he resigned, and
with a few patients went to live in a quiet suburban village
near Boston. A few month's later he died suddenly of heart
disease.

The only work which Dr. Day wrote was “ Methomania,”
which had a large circulation in its day. It was an excellent
summary at the time of the facts of inebriety, and was a very
useful influential work. His annual reports,and lectures to
various societies, and papers in the Journal, were all of an
exceedingly practical character. We are too near to judge
clearly of the great work Dr. Day accomplished.

A sorrowing family, consisting of a wife, one son, and two
daughters, survive him. Beyond this, his influence and mem¬
ory continues in the hearts and homes of a vast army of men
and women who have been made better by his life.

We present a fair portrait of Dr. Day in this number of
the Journal and assure our readers that in the coming cen¬
tury he will be one of the few men whose life work will be
studied with critical interest.

Buffalo has the discredit of having the largest number
of liquor saloons in proportion to its inhabitants. In Phila¬
delphia a license cost $1,000, and there are 1,355 saloons, or
one to every 841 persons. In Boston a license costs $i r
500, and there are 1,080 saloons, or one to every 500 persons.
In New York city a license costs $200, and there are 7,300
saloons, or one to every 234 persons. But in Buffalo, a saloon
license costs only $125, and there is one saloon to every 160
persons.

Vol. XVIII.—8

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Trance-double Consciousness , etc.

TRANCE-DOUBLE CONSCIOUSNESS, ETC.

By C. Spencer Kinney, M.D., Middletown, N. Y.

Assistant Physician , Asylum for the Insane .

The following unique cases are presented for the consid¬
eration of the society, as the psychical changes here noted
came under my immediate observation.

Case /. — For a number of years G., aged 28, had been
a periodical drinker, at which times he had not hesitated to
take anything containing alcohol, going so far as to be wholly
content with commercial alcohol so long as there was enough
of it. He possessed a remarkable physique, with a very
even commingling of bilious, nervous, and phlegmatic tem¬
peraments. He was well educated, had traveled considerably,
and the effects of his frequent debauches had produced no
apparent degenerative results. He was an accountant, and
capable of occupying a good position. At no time had he
shown any especial mental symptoms. There had been no
insanity in his family, and his drinking had become an
acquired habit rather than a disease. The attacks of drink¬
ing varied from intervals of a week to several months.

The instance which I have to mention in his case arose
at a time when he had been for some days without drinking
at all, and was in excellent physical condition. While out of
doors and walking briskly, and in exuberant spirits, he
suddenly heard some unfortunate news — news that affected
him personally. As soon as he was able to appreciate the
importance of the information and its bearing upon his future,
he suddenly took on all the appearance, actions, and helpless¬
ness of a drunken man. He staggered in his gait, stam¬
mered, stuttered, and mouthed his speech. The expression
of his face changed to a sottish cast, his eyes became suffused,
and he needed the assistance of a friend to make his way
along the street. This continued for over half an hour
before it passed off and he was able to collect himself.

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I had never seen an instance of this kind before, and
although fifteen years have passed since this case came
under my observation, I have never seen its counterpart.

Four years ago last October I presented a short paper to
the Homoeopathic Medical Society of the State of New
York on ‘‘Alcoholic Trance/’ Since that time I have met
a number of instances of this peculiar condition, and one of
which I was fortunate enough to be present at the transition
from the trance state to one in which he became appreciative
of his surroundings.

No. 4131 ; age, 27 ; married ; occupation, laborer; predis¬
posed by inheritance to insanity ; assimilative powers weak,
and his general appearance showing a lack of harmonious
development; was admitted to the Middletown State
Homoeopathic Hospital May 9, 1894. His friends state that
during the past twelve' years he has had times when he would
suddenly leave his work and home and be absent a week or
two without either knowing his whereabouts or, on his return
home, being able to give any account of where he had been
or what he had been doing previous to the time of regaining
consciousness. He had used tobacco freely and had drank
occasionally, but never to any great degree, although easily
influenced by either one of these two agents. The death of
his mother brought on a depression of spirits that was
followed by a condition of excitement in which his friends
became alarmed. Suicidal tendencies developed, and, for
safe keeping, he was placed in the jail, when one of our
nurses was sent for him. From the time the nurse saw him
until he reached the hospital, a period probably embracing
thirty minutes, the patient was continually talking to the
nurse about fighting, and telling what he could do. He
showed considerable irritation because the nurse would not
fight with him, and called him many names.

I happened to be on the ward when the patient came,
and on attempting to talk with him he showed irritation,
and was overbearing in his manner without any apparent
reason. Finally I asked him if he would not sit down and

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talk the matter over quietly. He consented, although no
change occurred iri his general style of acting until he
stopped suddenly, pressed his hand to the back of his neck,
and, looking about him with some degree of interest, said,
“ Where am I?” I asked him where he thought he was.
He said, “In some hotel.” On being told the character of
the place he quickly answered, “ Why, my brother was
employed here for some time,” which was true. With this
his manner completely changed ; he was pleasant, exerting
good self-control, showed no trace of his recent irritation,
and had no memory of anything that had occurred directly
previous to his coming here or of his great desire to quarrel
with the nurse who accompanied him to the hospital. From
that time until he was discharged, several months after, he
presented no symptoms not to be found in a case of ordinary
melancholia. How long he had been in this trance state he
did not know, nor could any facts be gained from his friends
that would point to any clue, although the duration of the
time in which he was said to have been sick was given as one
month previous to his admission.

The peculiarities of this trance condition have struck the
novelist as being an unexplored mine. An article in the
Cosmopolitan for February, 1894, entitled, “The Disappear¬
ance Syndicate,” by T. C. Crawford, and another article,
“ People Who Drop Out of Sight,” written by Dr. E. A.
Osborne, in the Medico-Legal Journal for June, 1894, are
worthy of careful consideration.

The next case is one of somnambulism that has some
peculiar features. This patient was a strong, athletic young
man of 21; single; occupation, law student; of good
education and habits, and with no insanity in his family
history. On his admission, his pupils were somewhat dilated,
bowels inclined to constipation, had a good appetite, was
coherent in his speech, feeling in good spirits, and gave the
following history : In July, 1893, he with a party of several
others, rode to Washington, D. C., on their bicycles. One
day during their journey the party covered about 120 miles

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over quite a rough road. They rode in and about Washing¬
ton, and returned to Brooklyn on the cars. The patient
rode from Hackensack, N. J., to Middletown on a very warm
day and suffering from a sharp attack of diarrhoea. He felt
weak on reaching home, as well as on the following day, but
immediately resumed work. At no time during his trip was
he conscious of being overcome by the heat, although he
had exercised violently several consecutive days, riding from
six in the morning until ten at night, with only an occasional
stop during this time. About two weeks after his return
home he began having headaches. They came on in the
morning on getting up, and continued until about five in the
afternoon. The pain -began in the forehead, extending over
into the back of the head and neck and was throbbing in its
character. When the headaches prevailed, the patient had
no appetite and occasionally had water-brash. They came
at irregular intervals, occasionally coming on every day
for two or three days and then skipping a week or two.
Nothing seemed to aggravate them during the day. Follow¬
ing this condition came frequent attacks of somnambulism;
in which he would dress in his bicycle suit, and at other
times would not dress at all, and, taking his wheel, would ride
about town and into the country, usually meeting with some
accident that would awaken him. These accidents generally
resulted from his being unable to use the same degree of
judgment when in this trance-like condition that he would
exercise when awake. One night in August, 1893, he got
up, and dressed only in his undershirt, rode his wheel out of
town, down a steep hill, and woke up lying on his back, with
his head bn the edge of a pond of water and his wheel about
thirty feet distant. His fall awakened him. At another time
he woke up and found himself suspended in the air, by his
shirt, from the limb of a pear-tree in his father's yard.
Whether he had fallen from the roof of the house or whether
he was trying to get on to the roof, he has no way of knowing.
At other times he has gotten up and gone to the office at
which he was employed during the day, filled out a copy of

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service, and had the same correct, although not remembering
anything about it afterwards. One day he worked hard in
the settling up of the accounts of an estate, and found that he
was unable to draw a balance. He was, at last, obliged to
give it up for the day. The next morning, on returning to
the office early, he found the balance correctly drawn, and an
error corrected that he had repeatedly overlooked the previ¬
ous day. These experiences gave rise to his facetiously
remarking, 41 1 guess I am smarter when I am asleep than
when I am awake.”

These experiences simply illustrate what the patient has
gone through during the past eight months, bicycle riding
and office work being the things he indulges in during these
attacks of sleep-walking. The patient has no memory, when
he comes to himself, of what he has done during these
intervals. The attacks, he claims, leave him with a sensa¬
tion of exhaustion that he carries with him the next day.
At times objects appear as if they were a long distance from
him. His first night’s record was a counterpart of many
nights. His roommate stated that he got up three times.
Once he jumped out of bed suddenly and banged into the
door of his room, which was locked, and bumped his head
against it so suddenly that it awakened him. Another time
he ran against the wardrobe and wall with so much force
that he woke up. The third time he tumbled over his room¬
mate and his bed, which also awakened him. He returned
to his bed each time with no serious results from the attacks.

As an illustration of what he would do when asleep, I
present the following as coming directly under observation.
As a rule, he went to sleep almost immediately on going to
bed. At a quarter past nine I found him up and walking
about his room, talking as if he were speaking to some one
at the telephone. He carried out his part of the conversation
quickly and in a spirited manner, correcting himself on
making mistakes. His mind appeared to dwell wholly upon
business relating to the office he had been working in. Every
effort that was made to awaken him was met by him with

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violence — striking or pushing. He could be lifted about or
pinched, called to, shaken, and cheek slapped, with no result
so far as getting him awake. The fumes of ammonia were
placed under his nose, when he suddenly came to, bright and
with perfect control of his faculties. The patient said he had
no memory of what he had been saying, nor did he know that
he had been talking. Another night he jumped up on the
top of his wardrobe, where he sat with an open umbrella
over his head, and talked rapidly and incoherently for some
time, until he was rescued from his perilous position and put
to bed. It was found that any excitement during the day
induced a disturbed night, consequently every effort was
made to have him lead as quiet and uneventful a life as
possible. Company was avoided, attendance on dances and
witnessing ball games were prohibited, and no exposure to
the hot sun was allowed.

Another instance, peculiar in its character, occurred on
the evening of June ioth. While sitting on a balcony,
talking in a lively manner with some of his fellow-patients,
the chair in which he was sitting slipped on the floor and he
fell, striking the back of his head with considerable force.
He was at once picked up, and was found to be sohnd asleep,
was taken to his room and efforts made to awaken him,
which were met with the usual resistance. On being awak¬
ened he complained of pain in the back of his head, and hot
water was applied, but almost immediately he went to sleep,
and continued asleep until morning. Each morning it was
found necessary to awaken him, although it was a less diffi¬
cult matter than when he was in one of his somnambulistic
states. On August 7, 1894, there had been a gradual
improvement in his physical and mental condition, without
any essential change in the character of his attacks, although
they appeared to be less in degree. On the 7th he com¬
plained of a headache, that he described as a sharp, hard,
frontal headache, and after a careful study of the symptoms
it was decided to give him natrum muriaticum, which was
given in the 30th potency every three hours. From the

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time he began taking this remedy his symptoms lessened in
severity, his sleep became more restful and he woke in the
morning of his own accord, free from all headache and with
good self-control, was more hopeful regarding his case, and,
in an indescribable manner, felt better than he had since his
sickness began.

On September 20, 1894, he was paroled, and his parole
has been renewed from time to time in order that we might
keep his case under observation ; he reporting at the hospital
every three or four weeks. On November 9, 1894, he
returned and made the following statement: “Before I
began being disturbed in my sleep I was passionately fond of
music, both instrumental and vocal. During the last few
months while under medical treatment I have refrained from
having anything to do with music, even to the giving up of
playing on my banjo. Since I have been away from the
institution on parole,,I have found myself unable to listen
to a combination of instrumental and vocal music, the
vocal music having the effect of making me nervous and
restless to the extent that I have been unable to remain in
the room or house, or in fact within hearing of it. Instru¬
mental music does not seem to affect me in the way that
both combined do. Several times a severe headache has
been induced by listening for a short time to music, I at first
believing that such an effect could not be produced, and it is
only after repeated trials that I have become convinced that
the above is the case.” (On February 9, 1892, I presented
a short article to the New York State Society nn “The
Influence of Music on the Insane,” touching this peculiarity.)

While directly under our observation every effort was
made to prevent his being subjected to any emotional strain,
and he was cautioned to lead as much of a vegetative exist¬
ence as possible. While here, previous to the natrum muri -
aticum , he had aconite , belladonna , and, for a while, five
drops of the tincture of cimicifuga rac . every night on going
to bed. This seemed to give marked relief, and lessened
the intensity of his headaches. While he is still under

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observation it is not likely that he can, with any degree of
safety to himself, take up any intellectual brain work for, at
least, a year.

The next case mentioned was reported by Dr. Talcott at
the annual meeting of the Medical Superintendents of the
American Institution for the Insane, held at Old Point
Comfort, Va., May 18, 1888. No. 2207 was admitted to the
Middletown State Homoeopathic Hospital November 17,
1887. This patient was a male; single; age, 18; occupa¬
tion, laborer ; education, common school; habits temperate,
and no record of insanity in the family. When admitted
he was in good physical condition, and his history declared
that down to the date of his injury he had been a bright
boy. During the past year he had been trying to earn his
own living ; part of the time keeping books, and part of the
time working on a farm in Westchester county.

On the 8th of October, about six weeks previous to his
admission to the hospital, while standing on the top of a
ladder, twenty-six feet in length, picking apples from a tree,
the ladder broke and he fell to the ground, striking on the
back of his head. He was carried into the house uncon¬
scious, and remained so for several hours. He remained in
bed only one day. A few days after the accident he returned
to his home in Delaware county. From the date of his
accident to the time of his admission, he is said to have
spoken but two or three words. He could not speak when
admitted; but during his entire illness he was able to com¬
prehend questions written upon paper, and would answer
these questions readily and rationally in writing. In his
written replies he states that all spoken words sound like
noises to him, but have no meaning. He could hear a low
tone of voice but not a whisper. In writing answers to
questions he does so quickly, and shows a clear compre¬
hension. He asks questions intelligently by writing, and
says that he has a dull steady pain from the base of the
brain down the spine to the small of his back, and this pain
is aggravated by any sudden jar. On examination, the spine
Vol. XVIII.— 9

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from the first lumbar vertebra to the skull was found to be
very sensitive to touch and pressure. He says that exercise
does not tire him, and he has for several weeks been allowed
to do as he pleased. He has spent much of his time out
of doors playing with a large Newfoundland dog, to which
he became much attached, and which attended him when he
came to the hospital.

On the 13th of November he became much enraged at
his mother, who would not grant some request he made, and
he flourished a long knife and tried to injure her. On being
shut up in a room, he broke the door and was very violent.
His friends then had him committed to the hospital at
Middletown, where he arrived November 17, 1887. When
admitted his pupils were normal in size, and the reaction was
natural. The tongue was clean and firm, with no muscular
tremor. The pulse was 78 ; the temperature was 98.4° F.
The patient weighed 150 pounds, and seemed generally in a
good physical state. He had a good appetite, slept well at
night, stated in writing that the pain in his head had ceased ;
and he deported himself like a bright, good-natured, active
boy. But he could not hear distinctly, and he could not
speak at all, although apparently comprehending everything
that was written and placed before him.

Here was a case of motor aphasia or aphemia (can write
but cannot speak), resulting from a blow upon the head,
with occasional attacks of maniacal excitement; the excite¬
ment being displayed by restlessness and ebullitions of rage,
without any ability to give articulate utterance to his
emotions or passions. Although the patient had been
allowed to walk about as much as he pleased for nearly six
weeks, we concluded it would be better for him to remain
quiet. Consequently we placed him in bed and kept him
there.

November 19th.— Writes on paper that he caught cold
last night, and when he coughs it hurts his head. On the
23d, about 9 a. m., he wrote on a slip of paper ‘‘headache,”
and gave it to the attendant. About 11 a. m., the pain

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in the head had increased, and at 11.30 a.m. he was rocking
backward and forward in bed with both hands pressed tightly
against his head, one being over the forehead, the other over
the occiput and upon the seat of the injury. His face was
flushed, pupils dilated, and the eyes deeply injected. While
I was noting these symptoms, he suddenly removed his hands
from his head, looked up like a person awakening from sleep,
gazed about the room in. an, inquiring manner, turned to the
window, looked out for a moment, then suddenly turning to
me said, “ Where in the devil am I?” These were the first
coherent words uttered since the injury. This patient’s
mind went back to normal position with a snap, so to speak,
just as a dislocated bone returns to its socket when it is
u set ” by a surgeon. On being asked if he did not know
where he was, he said, “ Not in the least. I know I was
picking apples when the ladder broke and I fell, striking on
the back of my head. Oh, how it hurt! ” On being told
that it was some weeks since the accident and that he was
in a hospital, he said, “ Why, that was on the 8th of October;
what day of the month is it now ? ” On being told that it
was the 23d of November, he replied, “ To-morrow will be
Thanksgiving Day ; a lunatic asylum is a queer place to pass
Thanksgiving Day.” When told that he had not spoken
before since coming to the asylum, he said, “ I must have
been good company! ” On questioning him, he declared
that he had no memory of anything that had taken place
since his fall from the ladder. For six weeks time had been
a blank to him. He had become well acquainted with me
since his admission to the hospital and always recognized
me pleasantly on the morning visits. On the morning
mentioned he had anticipated my coming with hopes of
obtaining relief from his headache. A moment before he
became conscious of where he was he knew me and the
circumstances connected with our acquaintance ; the instant
he regained his normal state of mind I was a stranger to
him and he knew nothing of me.

After he began to talk his headache lessened. He was

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kept quietly in bed and given hot milk and beef tea every
three hours. The headache and tenderness along the spine
soon passed away, and no symptoms of brain or mind
trouble returned.

He remained at the hospital under observation until the
27th of February, 1888, when he went home in excellent
physical and mental condition. While his memory was
dislocated from October 8th to November 23d, he could,
after the later date, remember distinctly all the previous
experiences of his life, and all new experiences ; but he
could never recall any incident that occurred between the
dates just mentioned.

The abuse of alcohol has been the remote, sole, and direct
cause of more litigation in cases of life insurance than
anything else that can be imagined. — Judge Jordan .

It has been pretty well established that the children of
intemperate parents are afflicted with degeneracy and various
neuroses. Associate this, then, with suitable environment
and the drunkard or inebriate is an inevitable result.

Alcohol Poisoning and Strychnine. — Runkewitch in
the pharmacological laboratory of Professor Burzynski, of
Tomsk, studied the action of strychnine in alcohol poisoning,
finding that the drug rapidly and distinctly augments the
excitability of the motor area of the cortical substance of the
brain, previously depressed by alcohol. In this manner it
raises the action of the depressed respiratory centers and aug¬
ments the blood-pressure during alcoholic narcosis. It
affects the temperature only in doses large enough to cause
tetanus. The experiments of the author were made upon
animals, and further investigations are necessary in order to
determine whether his conclusions apply equally to man.

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kqd fjeview^.

ACUTE COCAINE-POISONING.*

M. V. Ball, M.D., Philadelphia.

In presenting this report of a case of acute cocaine-poison¬
ing, I doubt whether I can offer anything new, and yet there
are several interesting points to be noted.

The literature on cocaine intoxication, though widely
scattered, is, however, quite extensive. Mattison of Brooklyn
and Germain See of Paris have each reported, in 1892, two
hundred and more cases of poisoning, with twenty deaths.
Since then quite a number of deaths have been recorded in
medical journals.

The dose at which fatal poisoning has occurred varied
within marked limits. In five fatal cases reported by Man-
heim the quantity of the alkaloid taken was over 15 grains,
In two cases reported by Mattison death occurred after hpyo-
dermic injection of § grain.

Symptoms of poisoning have set in when the drug was
administered by the stomach, when thrown into urethra, nose,
ear, rectum, or when injected under skin or into the gums ;
or when simply rubbed over the surface of the face.

Absorption is very rapid, and in some of the cases re¬
ported the operator barely had time to withdraw the needle
of his syringe before symptoms of intoxication set in.

The symptoms described in each case differ greatly, and
there are all stages, from slight incoherency in speech, with
dizziness and dilated pupils, to excited hallucinatory delirium,
thready, uncountable pulse, convulsive breathing, or sudden
collapse, or marked tetanic spasms.

* Read before Philadelphia County Medical Society, October 9, 1895.

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Cocaine-poisoning exhibits the symptoms of strychnine-
poisoning in some cases ; in others, that of alcohol, and in
some a mixture of both.

I will describe the case in question :

Mrs. C., aged thirty-five years, white, a sufferer for ten
years past from rectal stricture, accustomed to use cocaine
locally on pledget of cotton in the rectum, being tired of her
existence, resolved to end her life by swallowing 25 c.cm. (6
drachms) of 5 per cent, solution of cocaine, equal to about 1 ±
grammes (i8£ grains) of the alkaloid.

The dryness in the throat was speedily produced, and, in
attempting to get up from her couch to ring for the servant,
she felt dizzy and fell to the floor. A young medical student,
living in the house, and summoned at once, found her in a
raging delirium. She wanted to throw herself from the bal¬
cony. She talked loudly, incessantly, and incoherently. She
was restrained by physical means, and when the student en¬
deavored to give her a hypodermic of morphine, she resisted,
and would not allow him to do so. He persuaded her to
take the tablets by the mouth, and so i grain was adminis¬
tered. It was about half an hour after that I saw the patient.
She was held down on the bed by her friends, and was gestic¬
ulating wildly, yet was able to recognize me as soon as I
entered the room, appealing to me for help. I suffered her
to be released, when, immediately rushing past me,-she made
for the open window to fling herself out. This she was pre¬
vented from doing, remarking, as she was led back to her
couch, that, after all, “ she wanted to look pretty when she
died.”

Her pupils were widely dilated, the pulse hardly percep¬
tible and very frequent. The tongue would be protruded
spasmodically, and teeth gritted together in a tetanoid man¬
ner. She talked incessantly. In a few minutes I was able
to gain control over her without using physical restraint; and,
though she talked irrationally at times, her delirium was less
marked, and she told me that she was not going to get over
the effects, nor would she allow me to give her an antidote;

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in the next breath she would ask me to listen to her singing
or recitation. Frequently looking at her hands, they appeared
dirty to her, and she would rub them. Her tongue was much
congested, bluish, anaesthetic. Her throat was very dry;
other parts of the body, tested superficially, gave no indica¬
tion of anaesthesia.

Respirations were normal. Temperature normal. Pulse,
when counted, was 140. She stated that she felt glorious—
never so happy before; wanted to drink champagne, and
when it was brought to her, forgot that she asked for it.
Delusions of persecutions were present to a slight degree,
and her most intimate friend was accused of treachery and
underhandedness. She was desirous of moving around ;
wanted to leave the house and visit a place she had not
thought of for many years. Gradually a feeling of tiredness
supervened, talk became less lively, bodily sensations were
now complained of, and especially great thirst, which water
or ice had no power to quench. Lemon and vinegar applied
to lips was tasted, showing that sense of taste was not entire¬
ly absent.

Pulse still very frequent and small; was able to adminis¬
ter black coffee and lukewarm water, and thus induce free
emesis. At this time, which was two hours after the cocaine
had been swallowed, the patient was resting quietly, with her
pulse stronger, but still rapid. Thirst was extreme, and in
attempting to go to bath-room, she found her legs almost
useless. The urine was passed. Strychnine, grain 3^, was
administered by mouth, and some champagne was given.
Perspiration started on skin, and the former pallid condition
of face changed to a slight glow. Four hours after the initial
onset the patient was sleeping soundly, and the pulse went
down to 100, but was much stronger. Consciousness entirely
returned, but no recollection of time, and little of previous
events, although she remembered when I came in. Next
morning she was very weak, her body felt bruised, and her
limbs heavy and almost useless. Feces and urine had been
passed without trouble. No appetite. Tongue and throat

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still much parched, and thirst still present. Congestion of
tongue was gone, and normal sensations had returned.

A history of a previous overdose was obtained. The
alkaloid in dry state was taken by mistake, and an active
delirium, much worse than the one just recorded, occurred.
Morphine was administered in large quantities at the
time.

Very few cases are on record of recovery from so large a
dose as the one taken in this case, although in a case where
22 grains were given by mistake, by the mouth, patient died
almost immediately. Forty grains have been taken daily by
persons habituated to its use. Recovery would probably not
have occurred were it not that patient was under the influ¬
ence of the drug, more or less, for some time past.

One of the earliest, possibly the first, case of cocaine
poisoning is recorded by H. Ploss in the Zeitschriftfur Med-
icin t Chirurgie und Geburtschilfe, vol. ii, 1863.

Nieman, who was the first to isolate the alkaloid and
gave it the name it now bears, made known his discovery in
1859; but this fact was known to a certain apothecary who
was experimenting with cocoa leaves, and who, in 1863,
thought he obtained a poison from them as, fatal in its effects
as strychnine. He took of this extract a considerable quantity,
with a view of ending his earthly existence, and, while wait¬
ing for the drug to take effect, he joined some friends in a
beer hall and indulged in a few mugs of beer. He then
retired to his bed and fell into sleep. Some three and a half
hours after he took the poison he awakened with severe
thirst and dryness in mouth, dizziness in head, and in
attempting to walk across the room his legs gave way. He
was unconscious then of what occurred until the morning,
but, from the appearance of his room, he must have been
rather active. In the morning he felt very weak, and still
dry in mouth, and thirst.

In the cases of poisoning that I have been able to collect,
frequency of pulse, dilatation of pupils, convulsive twitchings
of face and general convulsions, respiratory muscle spasm.

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unconsciousness, excited delirium, suppression of urine, and
cyanosis are the symptoms most common.

The delirium is to be distinguished from alcoholic deliri¬
um from the absence of frightful hallucinations. Hallucina¬
tions are rarely present. One, the so-called cocaine bug, and
which occurred in my patient, is believed by Erlenmeyer to
be due to disseminated scotoma.

Spots of dirt are seen on white surfaces, as noted in this
patient, the fingers seemed black and dirty.

LeGrain states that alcoholic tremor is wanting, but it
was distinctly present in our case. The thirst and dryness
of throat is a distinguishing feature. Otherwise, without a
history, they seem very much alike.

Moreno Y. Maiz (. Recherches Chemiqne et Physilogique
sur l. Erythroxylon Coca, 1868) states that the thoughts are
not mixed up as in alcoholic intoxication. The phantasms
are brilliant; there is a flow of wit. I have seen in an
advanced case of general paresis a similar delirium—a desire
to sing and recite, to move about, to express a feeling of hap¬
piness. An habitue of cocaine has expressed himself as
desiring ten years with cocaine rather than 10,000 centuries
without it. The element of grandeur and personal aggran¬
dizement sometimes enters.

Dujardin-Beaumetz, in his Dictionaire de Therapeutique
Supplement , 1895, states that the effects of cocaine in toxic
doses in warm-blooded animals are similar to strychnine, but
in cold- blooded animals — the frog, for instance — no convul¬
sions are produced.

It is a curare for the sensitive nerves, exciting the nerve-
trunks, and rendering the peripheral nerves analgesic.

Francois (Arch, de Physiologique> 1892, p. 562) finds it a
paralyzing poison, not only on the sensitive fibres, but also
on the motor, and on the fibres of muscles as well as the pro¬
toplasm of cells.

The frequency of pulse is probably due to paralysis of the
vagus; the prenic nerve is likewise interfered with, causing
the respiratory spasms and tetanic arrest in some cases.

Vol. XVIII—10

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In my case there was no interference with the urine.
The urine is often suppressed ; other secretions, as those of
the mammary and sub-maxillary gland, have been noted as
likewise affected by toxic doses.

Maurel thinks that death is due to destruction of leuco¬
cytes, their dead bodies collecting in capillaries and form¬
ing embolic processes.

Reclus holds that thrombi form in veins, and when death
occurs after an injection under the skin, it is due to the pen¬
etration of a small vein.

This will hardly account for the deaths happening after
the drug has been thrown into the urethra, or when swallowed
by the mouth.

As to treatment, I cannot offer anything suggestive.
Morphine has been looked upon as antagonistic, and has
been given in the majority of cases recorded where symptoms
of collapse are present early, with tetanic convulsions and
cyanosis. Nitrate of amyl is indicated.

Where heart’s action is weak, stimulants, strychnine,—
hypodermatically,— alcohol, ammonia, and ether have all been
suggested and tried.

The early administration of £ grain morphine did probably
influence the course in the case described, but recovery is
often rapid without any treatment.

As the poison is eliminated rapidly by the urine and skin,
the free action of these organs is desirable, especially as there
is a tendency for them to be less active than usual.

While the dosage of cocaine cannot be said to have any
well-defined limits, several clinicians, among them Hanel and
Decker, believe that £ grain, hypodermatically, should be the
maximum dose. — Medical and Surgical Register.

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THREE HUNDRED AND TWENTY-FIVE CASES
OF INEBRIETY. By R. M. Phelps, M.D., Roches¬
ter, Minn., Assistant Superintendent Rochester State
Insane Hospital, Rochester, Minnesota.

As holding a position by reason of which I have had
some 400 admissions of inebriates, representing some 325
individuals, pass under my observation, mostly during the
past five years, surely some resume of such observations and
some deduction based upon the same should be of value. I
here simply wish to group a few of the impressions which
have grown out of such work.

1. Kind of Patients Received: Patients received have
been such that their behavior made it seem that they could
not otherwise stop drinking, or that they had in some way
become obnoxious to society. They were mostly, therefore,
what are called confirmed inebriates, or in the later stages of
inebriety. Of these inebriates ten have received the Keeley
Cure, and about twelve have received cures, which, under
other names, had yet pursued the same hypodermic medica¬
tion. Nineteen had also definite mental derangements,
quite sufficient to have committed them not as inebriates,
but as insane. Others showed varying grades of mental
impairment, but about 80 per cent, would, by all ordinary
tests, be sane and responsible.

2. Is Inebriety a Disease ? This is perhaps still a
living question, but would be better stated as follows: In
what way is inebriety a disease? The question, indeed,
calls for definition rather than argument. We, personally f
would define alcoholic inebriety as the drinking of alcoholic
liquors (not “excessive” drinking, for that makes an inde¬
terminate and variable drinking). Then, inebriety (drink¬
ing) would be a cause of certain diseased conditions, of
which the kidney lesions would be most prominent in some
cases, lesions of the liver in others, neuritis in others, and
brain lesions (causing mental impairment) in others, and so
on through less common lesions. This conveys a different
meaning from that given by the simple statement that

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“ inebriety is a disease/’ The difference is considerable.
As a subordinate fact, of course, it is to be allowed that
occasionally a nervous or mental weakness induces (rather
than “ causes ”) the inebriety.

Some subordinate questions may be anticipated. First,
some have assumed that there is always mental impairment
—“ obscure brain degeneration,”— and have assumed that
to be the disease, thus inferentially making inebriety one
form of insanity.

A bird’s-eye view of the whole field, however, will show
that there is the tendency to call only those inebriates who
have shown, as a mental symptom, a lack of control, which is
inferred to be a mental or moral reduction. But these are
not one in 25 of the whole number of drinkers. We would
think, then, the preceding statement not accurate. Though
every drinking in every drinking man may induce invisible
increments of mental reduction and brain degeneration (as
they may also, indeed, of the kidneys as well), so, also, may
many other causes which may be mentioned, etc., etc.

Secondly, direct heredity I have not been able to demon¬
strate in these cases. Indeed, as descending from a genera¬
tion in which a large proportion drank, drunkenness in the
father and child would indeed come as mere coincidences.
Fifty years ago drinking was not so disreputable as now. If
inebriety be inherited directly , as for example, inebriety in
the father, producing in the child a quick and uncontrollable
appetite for alcohol, it would not be exceeding strange,
although I personally have not met any such cases among
this chronic class.

Thirdly, periodicity rather fails to prove disease. Some
periodicities in people are normal, like that of menstruation.
Usually in insanity, though not clearly understood, it seems
quite clearly the sign of a defective constitution, usually
inherited. And in inebriety it is probably the same defect¬
iveness, in its exacerbations calling for alcoholic or other
relief.

3. Causes of Inebriety: Naturally these fall into two

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Abstracts and Reviews . 75

divisions. ( A) The causes of the beginning of the habit.
(B) The cause of its present excessive continuation.

In our list there are none noted, who started at the very
beginning of the drinking with an excessive appetite.
Though such cases are noted in literature, usually here from
five to ten or more years have been needed to bring about
their present condition. Their answers as to the causes are
various. Brain work, producing a nervous or neurasthenic
condition, is occasionally claimed. Not, however, more than
2 to 3 per cent, in the 325 cases. Worry of a family or
domestic kind is much more frequently spoken of, often,
however, we think, more as an excuse than a cause. In «
general, however, mere sociability has to carry all of the
blame of the early drinking, and this shows the trivial
character of such drinking.

As to the cause of the present drinking, the gross
inebriety, nearly every one will say that he loses control of
himself after taking the first glass. As to the feelings that
prompt this “first glass,” they are very vague indeed.
Rarely can they seem to know clearly. It is a kind of
mysterious vis-a-tergo impelling them on. Frequently it is
a kind of depression, produced perhaps by some family
trouble or worry. Occasionally one will describe a vigorous
fighting against periodical, overwhelming desire. Only
some three or four in the whole number, however, have so
described their appetite, and close study seems to show that
what happens is the coming of a depressed state, for which
they seek relief in alcohol; probably the current element
is the depression, instead of the appetite. Of course, also, as
in all movements, there is in alcoholism a tendency to
periods or sprees; the exhaustion from one attack leading
toward a remission, and a recovery leading toward a renewed
fall.

Briefly stated, the later stages of inebriety seem to be
caused by unstable nerves, calling for support. Morphine
produces a like condition of the nervous system, with its
tremulous unrest and pain, calling imperatively for some

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stimulant; and the stimulant in turn producing secondarily
the same condition which it tries to relieve.

Some prevalent erroneous ideas seem worthy of note.
First, drinkers rarely realize at all how hopelessly they are
bound, and the friends and relatives can hardly realize it
well either. In fact, only the persistent recurrence of the
subject under our observation makes us fully realize it. So
well, clear, rational and so seemingly of good intent are the
best of them,—so free from desire after a residence here that
it is difficult to believe.

2d. Drinking alone does not make an inebriate. The
♦ essential is a constitution affected by drink. Probably of
twenty-five who drink, only one is so constituted as to give
away fully to its control.

3d. Few drink because they like the taste of the
liquor. Even though they hardly know it, they drink for
the mental and physical uplift or well being. The gross
intoxication which follows is to them an undesirable
accident.

4th. Few drink because of an imperious desire. This
is the reason that they feel ordinarily so secure. Each new
spree seems to them a kind of “ happening ” ; they do not see
that it is always of this character, until toward the last of
their trouble.

5th. The more intelligent and highly educated the man,
the more complicated is the mental and nervous complex of
symptoms, the more apt to be exhibited the periodicities and
more apparent the brain failure.

4. Treatment: That the Keeley treatment is a
“ scheme/' even the popular mind is coming to believe; but
assuming strychnine to be the basis of the hypodermic treat¬
ment, I have used it (usually with some atropine also)
and have produced, to a large extent, the same incompatibil¬
ity to the drinking of liquor as described by the Keeley
graduates. There was here no revival to help it out, and I
did not have the same most promising subjects, as were selec¬
ted by Keeley, especially during his early work.

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For the most part our patients fell back. Strychnia
seems, to be the central drug in treatment, however. Of
other tonic treatment, and the treatment of any causal or
complicating lesion, no detail is called for here, nor need the
judicious use of baths, electricity, exercise and general
hygiene be advocated.

All told, however, the inevitableness of the relapse is
appalling. I always look with favor on the as yet fancy
picture of a colony made up of such people with their
families ; a colony large enough to furnish all of the trades
and occupations, and the living of a life just as at home,
with only one restriction, and that is the keeping of them
with their bounds and free from liquor. This is, of course,
in final analysis practically only a local prohibition law, and
it is an even chance to wonder about, whether this or general
prohibition will come first.

Twenty-five to fifty years from now will doubtless show
wondrous changes. For, after all is said, men struggle with
the results of this drink,—annually a million men are being
impaired in their work, and probably some 200,000 men
with their families are yearly in despair, disgrace- and
probably 100,000 die when logically the prohibition of the
drinking is as much the easier as would be the quarantining
of cholera, instead of letting it freely in and then drugging,
legislating, and trying to cure, the sufferers, which steadily
are taking the disease.

When, simply to shut the saloons of New York city
over Sunday almost pulls down the power of a law that tries
it, we simply confess that we want the cholera and will
stand our chances. It is beginning, however, to be common
for newspapers to denounce the traffic in liquor, which is an
index of the forward swing of public opinion, and this, as its
overbalance toward prohibition becomes more probable, will
act the faster, and some kind of prohibition or restraint will
rapidly prevail. —Medical Fortnightly .

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7«

^Abstracts and Reviews .

INEBRIETY AND INSURANCE.

In a paper before the London Insurance Association, on
“Doubtful Cases,” by Dr. Dreschfeld, occurs the following:

“ Dr. Dreschfeld went on to speak of those cases which
were classed as doubtful because the family history showed
some hereditary disease, although the individual proposer
had unexceptionable health. He mentioned consumption, can¬
cer, gout, Bright’s disease, diabetes, rheumatism, epilepsy,
insanity, and intemperance, and put briefly before his audi¬
ence some of the principal considerations to be kept in mind
in dealing with proposers in whose family history any of those
affections occurred. With regard to hereditary intemperance,
he said that they met occasionally with a whole family of
drunkards, where both male and female children were affect¬
ed with the complaint. In such cases it must be looked
upon as an inherited disease rather than a vice. On the
other hand, they often noticed cases in which, though one of
the parents, or even both, were habitual drunkards, all the
children were abstemious, though they often suffered from
some nervous affection. As far as it affected life assurance
they might say that the intemperate habits, when inherited,
showed themselves at an early age, and were often fully
developed before the individual reached the age of twenty-
five. If, therefore, the proposer had reached that age, and
was of temperate habits, such a life might be accepted ; and
he would not except from this even the offspring of those
who, like publicans and hotel-keepers, had special temptations
to become intemperate, though in that opinion he differed
from some well-known authorities. From his own observa¬
tion, he must conclude that the children of publicans of in¬
temperate habits were often most temperate, and remained
so. Dr. Dreschfeld next spoke of a second group of doubt¬
ful cases, which included those where there was no hereditary
taint in the family history, but where the individual, either by
his occupation, mode of life, or from the result of some illness,
or because of the presence of some slight disorder, could not
be considered as an A i life. Among the occupations which

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Abstracts and Reviews.

rendered life risky he mentioned those which gave excep¬
tional temptations to over-indulgence in alcohol, such as
publicans and commercial travelers. As regards habits, the
most important to inquire about were as to temperance. In¬
temperance was the most formidable enemy to the safe assur¬
ance of life. They could not often in these cases rely on the
statements of the proposer, as some could “ carry drink 99
well and were not easily intoxicated, and often the evidence
of friends was not trustworthy. There were, however, cer¬
tain signs of alcoholism which might be inquired into by the
insurance agent — using, of course, a certain amount of tact
— with results which he had often known most useful.
Where the decided symptoms of alcoholism appeared the
“ life ” was no longer doubtful, but ought not to be accepted
at all.

TEXT BOOK OF NERVOUS DISEASES—A COM¬
PENDIUM FOR THE USE OF STUDENTS AND
PRACTITIONERS OF MEDICINE. By Charles
L. Dana, A.M., M.D., Professor of Nervous Diseases m
the New York Post-Graduate Medical School, etc., etc.
Third Edition. William Wood & Co., New York City,
1894.

The author. Dr. Dana, is a widely-known teacher in
New York, whose accuracy and thorough knowledge of men¬
tal and nervous diseases has given the profession great
respect and confidence in his ability to write an excellent
book. In this volume of over five hundred pages he has
compressed a most excellent summary of the present knowl¬
edge of mental and nervous diseases.

Special attention seems to be given to the anatomy and
pathology of nervous diseases.

Many of the anatomical descriptions are models of clear¬
ness, although appearing, in some cases, to be burdened with
technical terms, which could be made clearer in other forms.

The classification and description of these diseases are
excellent, and conservative in all questions of doubt; and the
Vol. XVIII.— ii

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Abstracts and Reviews .

reader, who may not be acquainted with the author and his
personal work, will feel great confidence in the accuracy and
soundness of this book.

In future revisions changes in the proportion of topics
will be made, and the scientific technique of terms will
undergo some changes. The work commends itself as among
the most valuable books on this topic which has been pub¬
lished. The excellent illustrations, clear type, make it very
readable.

A work of this class, from so prominent a teacher and
author, needs no commendation. It comes to a class of read¬
ers welcomed from the start. The third edition, already out,
shows the high appreciation of its value.

To all our readers we urge the value of this work, which
should be on the table for daily consultation.

The Scientific American is unrivalled for interest, and
each week brings a most fascinating table of contents.

The Voice still leads with increasing vigor the war
against saloons, and the effort to banish alcohol as a bever¬
age. This journal recognizes the value of agitation, in its
great problems of spirit drinking. Opposition, battling,
movement, excitement, all mean progress in the course of
years.

The American Journal of Psychology , edited by G. Stan¬
ley Hall, Clark University, Worcester, Mass., discusses with
great ability those various departments of psychology which
are attracting so much attention in the scientific institutions
of the world at the present day. The subject matter includes
the results of experimental investigations in psycho-physic
laboratories, studies in abnormal psychology, including the
insane, criminals, idiotic, blind, deaf or other defections or
degenerations, the anthropology of myth, custom, religious
belief, symbols, etc., among savages, and ethnic shocks,
studies of animal psychology, neurological researches, the
psychology of philosophy, ethics, aesthetics, theology, etc. It

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Abstracts and Reviews .

will be seen that the Journal discusses questions of great in¬
terest from a philosophical standpoint.

The January and February numbers of the Popular Science
Monthly , contain some excellent papers, and altogether this
journal is superior to all other science journals in the Eng¬
lish language.

The Homeletic Review published by Funk & Wagnalls,
New York city, would make an excellent present to a clergy¬
man, also be a most instructive magazine to every thinking
reader.

The Magazine Romance , which has heretofore been de¬
voted to fiction entirely, has undergone a complete change, and
is issued as a five-cent magazine, filled with illustrations of a
popular kind. The magazine is a novelty, the idea being to
emphasize the illustrated side of it rather than the text. There
are 48 pages containing not less than 60 illustrations, printed
from the best of plates on the best of paper. There are pictures
of noted painters, of people of the day, of actors and actresses,
of literary individuals at home. Scientific matters are treat¬
ed and amateur photography is given a generous space. Al¬
together the design has met with a cordial reception wherever
spoken of, and readers will be sure to profit by purchasing
the early numbers, which will form a perfect little picture-
book of genuine, contemporary interest.

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Editorial.

f^ditorikl.

JOURNAL FOR 1896.

The eighteenth volume begins with this number, and it is
a source of much pleasure to look back over the seventy-two
issues of this Journal and trace the direction and progress
of the scientific literature of the subject.

The intention expressed in the first number, of grouping
and giving form and shape to the many facts of this, the
most complex neurosis known to science, has been accom¬
plished to a far greater degree than anticipated. The
Journal has attained an eminence that is unmistakable, and
the demand for issues and complete sets from the great
libraries of Europe and this country is evidence of this fact.

The lofty contempt of some critics, and the sneering pity
of others at the folly or the theory of disease in inebriety, is
most significantly answered in the papers of this number.

Again we present a portrait and sketch of one whose life
work was devoted to this cause, who has dropped out of the
ranks of the living. We send to all our friends and readers
the warmest greetings and congratulations for the coming
year.

The progress of research and the mass of facts which are
accumulating far exceed the capacity of this Journal, and
point to the necessity of a larger number of pages or more
frequent issues to keep up with the demands of the subject.

CLINICAL STUDY OF INEBRIETY.

Some carping critics have expressed harsh contempt for the
work of students of inebriety, because it lacks physiological
research. These critics imagine that all advance in medicine
must be along lines of physiological and pathological work.

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Editorial.

Literally, the real knowledge gained from a physiological
and pathological study is very small compared with the facts
which a clinical study has revealed, and almost infinitesimal
compared with our ignorance of the vital processes, and the
means of controlling them. Every one feels the need of new
facts and the absolute certainty that they exist, only awaiting
the discoverer and pioneer worker. So far, inebriety has
been studied clinically. The aim has been to observe symp¬
toms and trace them back to some final causes. The physi¬
ologists would study the organism and seek to ascertain its
functional activities by an exact knowledge of its structure.
This is carried on by experiment, while the clinician follows
the line of observed facts.

The work of the clinicists is more difficult than the ex¬
perimenter. The latter can control the conditions, and vary
them with circumstances at will. The former is called on to
unravel and analyze an assemblage of phenomena of the
most complex character. When he succeeds in differentia¬
ting groups of related symptoms, and traces their connection
to some morbid process or lesion, he has advanced physiolog¬
ical and pathological knowledge as positively as any labora¬
tory experiments. The experimenter should realize that he
needs the proof of clinician to complete the value of his work.

The solution of problems of inebriety that depend en¬
tirely on the laboratory experience are open to many sources
of error. The same is true of grouping of observed facts and
efforts to find out what their true meaning may be. The
clinical study of inebriety must of necessity precede all other
methods. The experimenter may inquire into the conclu¬
sions taught by this method, and seek to prove them by ex¬
act laboratory work. It would seem doubtful to discover
many facts that are positive by physiological research. The
clinician may err in his analysis, the experimenter may ob¬
tain different results at different times from the same data by
similar methods. Both will fail to arrive at a degree of cer¬
tainty and completeness of facts. But together, both meth¬
ods will bring out conclusions and facts that can be relied

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Editorial .

upon. These critics are narrow and do not realize the scope
of the subject, or the vast field of research which must be ex¬
amined by clinical grouping and study of symptoms. The
pressing need is trained men who will study the facts above
all prejudice, and with no other motive except to arrive at the
truth.

The clinician and experimenter are both needed, and
carping criticism of each other is only a measure of the ex¬
tent of the ignorance of the critic.

MORAL INSANITY IN INEBRIETY.

While the term moral insanity is disputed, there is no
other name which describes so clearly many cases that are
obviously defective.

The inebriate whose mind seems unimpaired, but whose
conduct is wild unreasoning and insane in every sense, is an
example.

The man who is a model of uprightness, wisdom, and
good judgment, who suddenly drinks to excess in the lowest
company is clearly wrong. The usual terms, vice, wicked¬
ness, and depravity, convey no rational idea of the condition
of which such conduct is a symptom.

A number of persons are to all general observation free
from the common signs of mental defects or disorders that
attract attention as strange or unusual. Yet at intervals
they display the most insane conduct, in the use of alcohol
and other drugs. Many examples are familiar to all our
readers. Usually such cases after a short time of alcoholic
excesses display intellectual unsoundness along certain lines.

How shall we express this insanity of conduct, which
appears not to be complicated with unsoundness of mind ?

Disorders of the mind appear in which the physical con¬
dition of the body seems unimpaired. Disorders of conduct
are noted in which the average intellectual capacity and
ability for mental work remains the same.

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Editorial.

If the term moral insanity is used, it expresses in a
general way disorders of the higher moral centers manifest
in conduct more than in thought.

Secret alcoholics or inebriates who lead double lives,
appearing in public as exemplary, judicious people, and in
private by act and conduct as the most idiotic and insane,
are clearly of this class.

The disorders which manifest themselves in conduct are
local and no doubt limited to certain brain centers, and
functions, and do not extend to other parts of the brain.

Why these disorders should be limited to conduct to a
large degree is unknown.

Many serious mental diseases pass away and leave only
disorders of conduct as the lasting entailment. Yet a fair
degree of intelligence remains and most of the time rational
conduct follows. At intervals the behavior is clearly insane.

The sudden unusual change of conduct is to be referred
always to the motor side of a higher reflex act, and no doubt
is a reaction from some stimuli either within or without.

The alcoholic impulse which drives the victim to the
lowest surroundings for its gratification and displays the
most insane conduct, is disease. It may spring from con¬
cealed delusions as sudden imperative ideas which dominate
the mind to the exclusion of all other thoughts.

To the general reader insanity in all its forms manifests
itself in mental changes. The cases in which changes of
conduct only are manifest have not received the attention
they deserve. The inebriate more than any other class dis¬
plays insanity of conduct, particularly in the first stages.
Later failures of mind and defects of judgment follow.
A certain class of inebriates manifest more insanity of con¬
duct than of mental disturbances.

A large mass of facts await study and formulation in this
direction. Every asylum for inebriates furnishes striking
examples of this form of insanity which may be most aptly
called moral insanity. We refer to this topic again to give
emphasis to the fact that inebriety is always insanity, not as

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Editorial.

understood by the common or legal definitions of the present
time.

Inebriety is an insanity in the sense that every disorder
of the mind and conduct reflects a physical condition of the
body as a whole. No sharp distinctions of causations can be
drawn. Disorders of mind and conduct are alike physical
states. Moral insanity describes disorders of regions at
present unknown but clearly outlined by a mass of ever
accumulating facts.

Action of Morphine and Chloroform upon Leuco-
cytosis. — A. Popoff, from experiments on 38 dogs, con¬
cludes (. Tnaug . Diss.y St. Petersburg, 1895) that morphine
causes gradual though slight increase of the white cor¬
puscles without previously diminishing them. For this
reason it is a suitable hypnotic for animals. The action of
chloroform is similar, but more pronounced. Diminution of
the white corpuscles begins only on the third day, the num¬
ber of leucocytes of all shapes increasing until the third day,
when the number of multinuclear cells diminishes and that of
the young cells increases. Under inhalations of chloroform
the activity of the white corpuscles is disturbed and slackened,
but on awakening from narcosis the number is increased.
Transfusion of blood from a narcotized into a normal animal
always increases the number of white corpuscles in the latter.

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Clinical Notes and Comments.

8 7

dlir\idkl ]\fote$ cii\d Con\n)ei\t^.

CLINICAL REPORTS ON TRIONAL.*

By Dr. F. A. A. Boudeau, of Paris.

The following cases observed by me in the service of Dr.
Gaillard at the Hospital de Tenon, serve to illustrate the
various uses of trional as a hypnotic and sedative :

I. INSOMNIA DUE TO PAINFUL AFFECTIONS.

Case i. Henri D., butcher, 40 years old, suppurating
hydatid cyst, with very violent pain, which, at the time of his
admission to the hospital, supposed to be due to hepatic
colic.

March 23, 1895. Four hours* sleep from a hypodermic
injection of a moderate dose of morphine.

March 24. Took one gm. of trional at seven o’clock in
the evening and slept from half past eight till one o’clock.
One half an hour later fell into a sleep which lasted till six
o’clock in the morning. The sleep was quiet without night¬
mare, and the patient awoke feeling well.

March 25. Did not take trional. Sleep lasted about
three hours, restless and suffering a good deal of pain.

March 26. Took one gm. of trional at seven o’clock.
Slept from half past seven until five in the morning, the
sleep being sound without nightmare. On waking the
patient felt rested, and had no disagreeable sensations.

March 27, 28, 29, 30. Continues to take one gm. of tri¬
onal and sleep on an average, eight hours.

April 1. Did not take trional. Suffered a good deal and
could not sleep.

April 2. Took one gm. of trional and slept nine hours.

April 3. The patient was transferred to the surgical ser¬
vice. Each time that the patient took one gram of trional

* Thesis presented to the Faculty of Medicine of the University of Paris,
189s.

VOL. XVIII.—12

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Clinical Notes and Comments .

he slept from eight to nine hours on an average, and was
more comfortable during the daytime. On the contrary,
when he did not take it, he suffered a good deal and was not
able to sleep. No inconvenience was ever noted from the
medication.

Case 2. Ferdinand D., tinsmith, 17 years old, attack of
lead colic, which prevented the patient from getting any
sleep whatever.

March 25. One gm. of trional at seven o’clock. Slept
from nine till eleven and again from two till four. The sleep
was disturbed by nightmare. Pulse 70.

March 26. One gm. of trional at seven o’clock. Fell
asleep at eight o’clock and woke at four. The sleep was
profound, but broken by nightmares. Lumbar pains on
waking. Pulse 95.

March 27. One gm. of trional at seven o’clock. Slept
from eight till six. He woke once during the night, but
went to sleep again immediately. Pulse 96.

March 28. Did not take any trional. Slept well for
eight hours.

March 29. Did not take any trional. Slept for two
hours, restless.

In this case an average sleep of eight’hours was obtained
from trional, without causing any secondary disturbances.

Case 3. Claire B., 40 years old, domestic, attacks of
mild hepatic colic which have prevented sleep for fifteen
days. From time to time she was able to obtain a nap for
half an hour or so, but was soon waked by the pain.
Bromide of potassium was given in doses of 2 grams for sev¬
eral days without effect.

On June 20, she took one gm. of trional at seven o’clock
and slept from nine o’clock until five in the morning, waking
only once and then going to sleep again immediately. From
that time she continued to take one gram of trional, obtain¬
ing an average sleep of seven hours. No disturbances were
noted, except that during the last few days there was a little
diarrhoea.

Case 4. N., 45 years old, suffering from a neuralgia of

the diaphragm, which prevented her from sleeping more than
one or two hours each night. For several days, two gms.
of bromide of potassium was given without success. On
June 18, at seven o’clock, was given one gram of trional.
She fell asleep at ten o’clock and rested till three o’clock,
when she woke and immediately fell asleep again until five

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Clinical Notes and Comments.

o’clock. Some nightmare. On awaking there was malaise,
her head was heavy, and she staggered a little, but these
symptoms disappeared. June 19, took one gram of trional
at seven o’clock. Slept from half past seven until five
o’clock, rising once to pass water, but fell asleep again imme¬
diately. On waking, the same disturbances as the day pre¬
vious, so that she was obliged to lie down again for a few
minutes, but the symptoms soon disappeared. The hypnotic
action continued throughout the day, during which she slept
pretty soundly. The pains are less violent even during the
daytime, than they were the day before yesterday.

June 20. Took one gm. trional at seven o’clock.
Slept from nine o’clock until midnight, when she was waked
by colicky pains, having taken on the previous morning a
purgative which had up to this time failed to act. She sub¬
sequently slept from three till five o’clock. On waking,
no further unpleasant symptoms.

Case 5. N., suffering from lymphangitis of the arm, which
caused a good deal of pain and prevented him from sleeping.
Took one gram of trional for two nights in succession and
slept for nine hours the first night and seven the second.

2. IMSOMNIA IN CARDIAC DISEASES.

Case 6. Joseph M., metal cutter, 69 years old, with
aortic insufficiency, and albuminuria, oedema of the legs, and
oedematous rales at the base of the lungs ; sleep impossible
on account of the marked dyspnoea. Pulse no.

March 24. Took one gm. trional at seven o’clock. Did
not actually sleep, but there was a little drowsiness for two
hours. The general condition remained bad, but was not
aggravated. Pulse 120.

March 25. Took the same dose with the same lack of
result.

March 26. Did not take any trional. Slept soundly
from a hypodermic injection of a moderate dose of mor¬
phine. Pulse 92.

In this case trional was shown to be inferior to morphine
It had, however, no bad effect upon the heart.

Case 7. Yvonne M., day laborer, 54 years old, mitral
insufficiency with enlarged liver; several attacks of jaundice.
Usually sleeps about five hours each night, restless and
wakes two or three times to pass water. Her first experi¬
ence with trional was on the 5th and 6th of February, when

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Clinical Notes and Comments .

she took one gm. each evening, sleeping about eight and
twelve hours respectively. The sleep was profound and
accompanied by nightmare.

March 17. Took one gm. of trional at eight o’clock.
Up to ten o’clock there was no special effect. At this time
her vision became disturbed, the head felt heavy, and there
was a ringing in her ears. At ten o’clock the patient yielded
to an irresistible drowsiness and slept until four o’clock.
The sleep was heavy but without nightmare. On waking
she had pain in the loins, headache, a little drowsiness,
noises in the ears with pretty marked deafness, and a little
uncertainty in walking.

March 18. Refuses to take trional on account of the
disturbances just mentioned. The disturbances of vision,
hearing and the headache gradually diminished, but did not
disappear for several days.

Case 8. N., 45 years old, mitral insufficiency. Has not

slept for some time on account of the feeling of oppression.
Took one gm. of trional for five days in succession. Sleep
came on after an average interval of two and one-half hours
and lasted six hours. It was somewhat restless. No dis¬
turbance nor any bad effect upon the heart.

Case 9. N., 30 years old, nitral insufficiency, com¬

pensation well established. Does not sleep at all. During
eight days took one gm. trional each evening and slept on an
average two to four hours each night. The sleep was inter¬
mittent, but the patient was very much relieved by it. No
disturbances and no injurious action upon the circulation.

3. INSOMNIA DUE TO FEBRILE AFFECTIONS.

Case 10. Francois P., day laborer, 57 years old, left
lobar pneumonia, with frequent cough and abundant expec¬
toration. Sleep impossible. Pulse 95.

March 24. Took one gm. of trional at seven o’clock.
Fell asleep at nine o’clock and woke at five o’clock in the
morning, feeling very tired. He was awake two or three
times during the night, but only for a short period. He had
a good deal of nightmare. Pulse 90.

March 25. Took one gm. of trional at seven o’clock and
slept from half-past seven till one o’clock only. The sleep
was disturbed by nightmares. General condition very bad.
Pulse 140.

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Clinical Notes and Comments .

March 26. The trional was stopped on account of the
seriousness of his condition. Pulse 140 and thready. No
sleep.

March 27. The patient died.

In this case the trional gave an average of six to seven
hours of sleep.

4. INSOMNIA DUE TO A NON-FEBRILE PULMONARY
AFFECTION.

Case II. Madeline T.,64 years old, attack of pulmonary
congestion without fever. Insomnia due to frequent cough¬
ing. The patient has only slept on an average five hours
each night for the past week. No nightmare.

March 11, Took one gm. of trional. After two hours
had a continuous sleep of six hours, but it was broken by
nightmares. Awoke feeling somewhat tired and with a ten¬
dency to drowsiness. '

March 12. Sleep of the same character coming on one
hour after the administration of the drug and lasting seven
hours.

From March 13 to March 17. Did not take any trional,
and slept on an average five hours each night.

March 17. Took one gm. of trional at seven o’clock.
Slept from nine o’clock till five o’clock in the morning, with
nightmares. On waking the head was heavy, there was
headache, nausea, no staggering.

March 18. Trional stopped. Slept soundly from nine
o’clock till four, no nightmare, felt rested on waking.

March 19. Slept soundly from eight o’clock till four,
without nightiftare.

Case 12. Jean C., carriage cleaner, 43 years old, bacil¬
lary phthisis. His cough was so constant that he could
only obtain one or two hours’ sleep each night, and it was
disturbed by nightmare.

March 19. Took one gm. of trional at seven o’clock.
Slept from nine o’clock till midnight and again from one till
four o’clock. The sleep was interrupted by nightmare, and
the patient awoke tired and with a tendency to sleep.

March 20. Took no trional, and was awake the entire
night.

March 21. Took one gm. of trional at seven o’clock.
Slept continuously from ten o’clock in the evening till four
in the morning. Some nightmare ; a little tired on waking.

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Clinical Notes and Comments.

March 22. Took one gm. of trional at seven o’clock.
Slept soundly from nine o’clock in the evening till five in the
morning, followed by a little pain in the lumbar region.

March 23 and 24. The same result as on the previous
day.

March 25. Left for Vincennes.

The average amount of sleep has been seven to eight
hours. The only comment is that the restful effect was not
as great as would have been obtained from a natural sleep of
the same duration.

Case 13. L. M., bronze founder, 25 years old, pyo-
pneumo thorax, general condition very bad, night sweats.
Complete insomnia, notwithstanding the administration of
pills containing opium and hyoscyamus.

March 25. Took one gm. of trional at seven o’clock.
Slept from eight o’clock until two in the morning. The
sleep which had been somewhat restless, was not resumed.
Nevertheless the patient felt rested on waking.

March 26. Took one gm. of trional at seven o’clock.
Slept from half-past seven until four o’clock. Sleep restless,
and had pain in back on waking.

March 27. Trional stopped.

Case 14. Leon L., jeweler, tuberculosis. Remains in
a drowsy condition throughout the entire night without
actually sleeping. The cough is frequent.

March 12. Took one gm. of trional. Half an hour
afterward he fell into a good sleep lasting eight hours, with
two or three interruptions. No nightmare. Cough a little
less frequent. Awoke rested and comfortable.

March 13. Took one gm. trional. Two hours later slept
for six hours, but not continuously. Woke with nausea,
headache, and then two hours later fell asleep for two hours,
waking rested, the various disturbances having disappeared.

During the week following the same results were
obtained; the action of the drug continuing for one night
after its administration was stopped. The average duration
of sleep was eight hours.

Case 15. N., 25 years old, tuberculosis, with pneumo¬

thorax, very cachectic. Sleeps only about two hours each
night. Spends the rest of the time in coughing. Has
taken chloral, sulphonal, and opium without the least result.
For about a month he took 50 centigrams of trional and fell
into sleep on an average three hours later, the effects lasting
about four hours. Although the sleep was disturbed the

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Clinical Notes and Comments .

patient was somewhat rested by it. In this case the trional
never caused any unpleasant symptoms.

Case 16. N., emphysema. Sleeps only about one hour

each night, coughing the rest of the time. Has taken opium
without any advantage. For twenty days, took one gm. of
trional and on an average, one and a half hours later experi¬
enced a quiet sleep, lasting four to five hours. Never any
unpleasant symptoms.

Case 17. Abel A., 19 years old, pasteboard maker, suf¬
fering from pleurisy on the left side. Does not sleep more
than one hour each night. During the remainder of the
time he is so restless that he cannot remain in bed on
account of the severity of the pain at one point in his side.

June 19. Took one gm. of trional at eight o’clock.
Slept from half-past eleven until four o’clock, the sleep
being sound and quiet. On waking felt rested and had less
headache than usual.

June 20. Took one gm. of trional at eight o’clock.
Slept very well from midnight until eight o’clock. No dis¬
agreeable symptoms on waking.

The same medication was continued for five days, the
sleep lasting on an average seven hours, without any bad
effects.

5. Nervous insomnia.

Case 18. Louis V., sculptor, cerebral softening.
Patient is very restless, and walks about the room in the
middle of the night.

March 18. One gm. trional at seven o’clock. Was quite
as restless and sleepless as on the preceding nights.

March 19. Two gms. of trional at seven o’clock. Slept
from ten o’clock till four in the morning, waking several
times. He was less restless, although still somewhat talka¬
tive during his wakeful moments, but was quieter during the
daytime.

March 20. Two gms. of trional at seven o’clock. Slept
from nine o’clock till five. He was a little more quiet than
last night.

March 21. Two gms. of trional at seven o’clock. Slept
from nine o’clock till six. The patient was very quiet and
did not wake at all. He was much rested in the morning and
remained quiet during the entire day.

March 22. Took only one gm. of trional. Still very
quiet.

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Clinical Notes and Comments.

March 23. Took one gm. of trional. The patient was
a little more restless than the previous evening, as well as
during the following day.

March 24. Took the same dose. The restlessness in¬
creased and the sleep was reduced to three or four hours.

The administration of Trional was then stopped. In this
case there were never any bad symptoms following the rem¬
edy, but it was manifest that the dose of one gm. was quite
insufficient to give any result.

Case 19. Marie G., burnisher, 21 years old, subject to
attacks of minor hysteria, without loss of consciousness,
coming on almost every morning and evening. She wakes
almost every morning with a headache which persists in a dim¬
inishing degree throughout the entire day. When there are
no evening attacks she sleeps calmly for nine hours. After an
evening attack she has a very restless sleep for seven to
eight hours, which is interrupted by sudden startings. No
nightmare.

March 16. She has had a slight attack at four o’clock
and is very excited. The taking of one gm. of trional at
eight o’clock was followed immediately by nausea. She slept
continuously from half-past eight till five o’clock and was
restless but had no nightmare. On waking, felt rested, with
no tendency to drowsiness and no more headache than usual.
During the following day there were none of the usual
attacks.

March 17. No trional. Had six hours of quiet sleep.
But four hours after waking had a slight attack, the only one
during that day.

March 18. Took one gm. of trional at half-past seven.
Only slept about one hour, beginning at two o’clock, and
woke with lumbar pains. Nevertheless, the day following
was quiet and free from attacks.

March 19. Took one gm. of trional at half-past seven.
Slept from eight o’clock till one. The sleep was light, the
patient awaking at the least sound, but falling asleep again
immediately. When she woke at one o’clock, she was rest¬
less, felt compelled to walk about, and had a peculiar sensa¬
tion of heat with urgent thirst. Although the patient was
tired, she was more quiet during the next day, and there were
no attacks. .

The trional was then continued for six days with the same
result. The average amount of sleep was about six hours,
but it was somewhat disturbed and did not give very much

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Clinical Notes and Comments.

rest; on the other hand, although the trional was given in
small doses, it seemed to exercise a very favorable influence
on the number of attacks.

Case 20. Louise H., day-laborer, 43 years old, slight at¬
tack of rheumatism, neurasthenia. For the past three or
four weeks she has only had, at the most, two hours of rest¬
less sleep each night.

March 18. One gm. of trional at eight o'clock. Slept
well and quietly from nine o'clock till eleven, but not after
that time.

March 19. One gm. of trional at eight o'clock. Slept
lightly from half-past eight till midnight, and felt somewhat
rested on waking. As the trional did not seem to give much
result its use was abandoned in this case.

Case 21. Adelaide B., jeweler, 39 years old, chronic
alcoholism in a neurasthenic subject. For a long time she
has only slept three or four hours each night. Sometimes
this sleep was continuous and sometimes broken, but it was
always restless and disturbed by nightmare. Has profuse
perspirations. There is always a sensation of marked fatigue
on waking.

March 5. Took one gm. of trional. Three hours later,
slept for six hours. This sleep was sound, without nightmare.
On waking there was some nausea and a little headache with
some giddiness.

March 6. Took one gm. of trional. Went to sleep four
hours afterwards and slept for two hours only. There was
nightmare and nausea and headache on waking.

March 6-11. No trional given. There was a complete
absence of sleep.

March 11. The patient took one gm. of trional, and
three hours afterward had only two and a half hours sleep,
interrupted by nightmare. There was profuse perspiration,
nausea, and headache.

March 12. Took one gm. of trional. Two hours after¬
ward fell asleep for two and a half hours only. The sleep
was broken by nightmare. There was a little perspiration
but no headache or nausea on waking.

March 13. Took the same dose. Four hours afterward,
slept for five hours, but she was restless and woke fre¬
quently.

March 14 The same dose. Three hours of restless
sleep.

Vol. XVIII.—13

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Clinical Notes and Comments .

March 15. Took one and one-half gms. of trional at half¬
past eight o’clock. One-half hour later there was a sensation
of torpor and weakness, and at half-past nine an irresistible
desire to sleep. She slept lightly until ten o’clock, hearing
every sound, and the same light sleep interrupted by night¬
mare was renewed from eleven o’clock until three in the
morning. On waking there was lassitude and heaviness of
the head lasting all day.

March 16. Took one gm. and one-half gm. at half-past
eight o’clock. Began to sleep one hour afterward ; woke at
eleven o’clock, and immediately went to sleep again, waking
finally at three o’clock in the morning.

March 17. Took one and one-half gms. at eight o’clock.
Slept well from eleven o’clock till one, and immediately
after fell asleep again until four o’clock. On waking, there
was fatigue, nausea, and headache, the latter symptom, which
was not a constant one before the administration of the drug,
has become so since then.

*March 18. Two gms. of trional at half-past seven. From
half-past eight till eleven there was pretty intense headache,
great weakness, and profuse sweating. At eleven o’clock the
tendency to sleep was irresistible, and she slept from that
time until half-past three, but very lightly, hearing all that was
going on about her.

March 19. Two gms. of trional at seven o’clock. Slept
from half-past eight till three o’clock in the morning. The
sleep was light and restless ; she woke two or three times,
but went to sleep again immediately. On waking was very
tired, but had no headache.

March 20. Took two gms. and had a broken sleep, last¬
ing from quarter past eight till four o’clock in the morning.

March 21. The trional was stopped. During the next
two nights the patient slept for a few hours, and afterward re¬
lapsed to her former condition of insomnia.

In the case of this patient, a dose of one gm. of trional
produced a sleep of three to four hours ; with one and one-
half gms. an average of five hours, and with two gms. about
seven hours. The size of the dose did not seem to influence
the rapidity of the action.

Case 22. N., 56 years old, neurasthenia. Very restless,
sleeps about one hour each night. A dose of two gms of
chloral hydrate produces about three hours sleep.

May 17. Took one gm. of trional at half past seven o’clock.
Had a good, quiet sleep from eight o’clock till half-past one.

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Clinical Notes ana Comments.

Was not restless during the remainder of the night. Awoke
quite rested.

May 18. One gm. at eight o’clock. Slept well without
nightmare from nine o’clock till half-past four. At half-past
one o’clock arose to pass urine, but fell asleep again immedi¬
ately.

From May 18 until May 28 continued to take one gm. of
irional, and fell asleep on an average three-quarters of an
hour after the administration, the effect lasting about seven
hours. The sleep was quiet and the patient awoke feeling
rested, having only a slight dull feeling in the head, and a
tendency to sleep during the daytime. With chloral the con¬
dition on waking was more disagreeable, the patient contin¬
ued in a condition of drowsiness and felt less rested.

Case 23. L. P., 19 years old, shop-girl, major hysteria,
with attacks about every other day. Sleeps only about two
hours each night, is restless, and has frequent nightmare.
In the daytime she is very agitated and complains of violent
palpitations. She has never taken any hypnotic.

June 19. On account of the extreme agitation of this pa¬
tient, she was given a gm. of trional at the outset, — one gm.
at seven o’clock and another at eight o’clock in milk. She
slept from half-past ten till two o’clock, then set up on the
edge of her bed and soon fell asleep again until half-past five,
when she awoke quite rested, having only a slight dull sensa¬
tion in the head. The sleep was very quiet. The palpita¬
tions were less violent, and there were no attacks of hysteria
during the day. On the following day she received two gms.
each evening with the result of obtaining, on an average, eight
hours of sleep, a calmer condition during the day, and some
diminution in the frequency of the crises. Nevertheless, as
the condition of excitability was still quite marked, and as she
could not receive the necessary attention in a general hospi¬
tal, she was transferred to Saint Anne on June 27th.

6. Insomnia Due to Various Chronic Affections.

Case 24. Eugenie B., cook, 37 years old, had undergone
a laparotomy, thirteen days before, for a fibroma which the
surgeons were not able to remove, and which has been the
cause of a very profound anaemia from repeated metrorrhagias.
Fora month she has not had any continuous sleep. She falls
into a doze from time to time, and then, after a short nap,
will lie awake for an hour or more. No restlessness.

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Clinical Notes and Comments .

March 16. Took one gm. of trional at six o'clock. Slept
from eight till nine o’clock, and again from ten to twelve, and
then immediately fell asleep again till four o’clock. But the
sleep was very light, the patient hearing everything which
took place about her. No nightmare. Nevertheless she felt
on waking more refreshed than usual.

March 17. One gm. of trional at half-past six o’clock.
The same light sleep as before from half-past eight till eleven
o’clock, and again after an interval of a few minutes until
four o’clock.

March 18. One gm. of trional at seven o’clock. Slept
from nine o’clock till half-past ten, and again after a brief in¬
terval until two o'clock, but the sleep was very light, inter¬
rupted by frequent waking, and was followed by a sensation
of fatigue.

March 19. Took one gm. of trional at half-past seven
o’clock. Slept from nine o’clock until midnight very quietly,
and again from half-past twelve until four o’clock, but during
this latter period was very restless. Felt somewhat refreshed
on waking.

March 20. The trional was stopped. Sleep continued to
be broken in character. Never any unpleasant symptoms.
The average amount of sleep obtained was about six honrs,
but it was light and very broken.

Case 25. Catharine A., 42 years old, cyst of the ovary.
For a long time the patient has not slept more than two
hours each night.

April 23. Took one gm. of trional at half-past six o’clock
in the evening. Slept from seven till five o'clock in the
morning, quietly and without any interruptions. Awoke
feeling comfortable and refreshed.

April 24. One gm. trional at one-quarter past eight
o’clock. Slept from half-past nine o’clock till midnight.
Fell asleep again, waking for a few minutes towards three
o’clock, after which she slept continuously until six o’clock,
well rested. The use of trional was* continued for eight days
longer at the same dose. The average result was eight
hours of quiet sleep. After the drug was stopped, the patient
slept a little longer than she had previously.

Case 26. Amelie A., 18 years old, florist; chlorosis
with phlegmasia alba dolens of the right leg. Has slept
about half an hour each night for about a month, and is very
restless during the rest of the night. At the first trial, with
one gm. of trional, she slept eight hours on the first night

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Clinical Notes and Comments .

and two hours on the succeeding ones. At the second trial,
March 13th, she took one gm. of trional at seven o’clock in
the evening. Beginning five hours later, she had six hours of
continuous sleep without nightmare and was much refreshed
on waking.

March 14. One gm. of trional at seven o’clock. Fell
asleep, two hours later, for five hours.

March 14 to March 17. An average sleep of five hours.

March 17. One gm. trional at six o’clock. Two hours
later she slept for three hours, the sleep being restless.
There was drowsiness and lassitude, which passed off during
the day.

March 18. At the patient’s request the trional was re¬
placed by the same dose of sulfonal, taken at half-past six
o’clock. She slept from nine o’clock till half-past one, and
again from three o’clock till six, the sleep being quiet, re¬
freshing, and not followed by heaviness in the head. The
same results were obtained on March 19th and subsequent
days, the average sleep being about nine hours, and coming
on two and one-half to three hours after the administration of
the drug. Sulfonal in this case proved to be superior to tri¬
onal which only gave an average of five hours sleep. There
was not much difference in the rapidity of the action, sleep
coming on two hours after the trional, and two and one-half
hours after the sulfonal.

Case 27. Alphonsine A., housewife, 61 years old,
cancer of the stomach, can hardly be said to sleep at all
during the night. From time to time has a nap of a few
minutes.

March 18. One gm. of trional at seven o’clock. Slept
from half-past seven till ten o’clock, and again from eleven
o’clock till three, the sleep being sound without nightmare.

March 19. One gm. trional at seven o’clock. Slept
from half-past seven till half-past ten, and again from eleven
till five o’clock, waking, however, several times. On waking
the patient was much refreshed, felt better and was more
hungry than she had been for a long time. During the night
she perspired profusely, which had not occurred previously.

On six other days the same results were observed, the
mean duration of sleep being seven hours. No unpleasant
symptoms except the unaccustomed perspirations. The tri¬
onal seemed to have a good effect upon the appetite.

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IOO

Clinical Notes and Comments.

7. Insomnia in Dyspeptic Patients.

Case 28. Louise L., housewife, 34 years old, dilatation
of the stomach. For the past six weeks has only had one or
two hours sleep each night, and this has been broken by
nightmare.

From April 6 to April 11. Took one gm. trional
each evening at seven o’clock. Falls asleep toward nine
o’clock on an average and sleeps till midnight. Does not
rest well, and has more severe headache than before the
administration of the trional. Has profuse night-sweats
which were not present previously. No influence on the
gastric condition.

Case 29. N., 35 years old, dilatation of the stomach.

Has only two or three hours of heavy sleep interrupted by
nightmare.

May 20. Took one gm. of trional at half-past seven.
From eight o’clock until five, had a sound and quiet sleep,
without nightmare, and awoke feeling very much refreshed.

May 21. Took one gm. trional at eight o’clock and slept
very well from half-past eight till half-past four o’clock.

May 22. Took no trional and did not sleep.

From May 22 to May 28. Took one gm. trional each
evening, and, after an average interval of half an hour, sleep
came on, lasting six or seven hours. No bad symptoms.

8. Insomnia in a Morphine Habitue.

Case 30. Renee L., 32 years old, morphine habitue.
Has been in the habit of taking daily, twelve prayaz syringe¬
fuls of a 1-40 solution of morphine.

The patient is extremely emaciated, vomits frequently,
has palpitation and profuse sweating. Menses are regular
but very scanty. She came to the hospital on March 8th,
having already taken eight syringefuls during the day. She
was given two more during the evening of a solution of 1-50.

March 9. She received injections of four syringefuls of
1-50 with one gm. of trional after the evening hypodermic.
One hour later had a sleep lasting six hours. Pulse 80.

March 10. Four syringefuls of 1-50 and one gm. of tri¬
onal. After two hours, slept well for six hours without
nightmare. Pulse 76.

March 11. Three syringefuls of 1-50 and one of 1-100
with onegm. of trional. After an interval of five hours, had
a quiet sleep lasting six hours. Pulse 82.

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Clinical Notes and Comments .

IOI

March 12. The same dosage. Nine hours of calm and
refreshing sleep, coming on one hour after.

March 13. Three syringefuls of morphine 1-50 and one
gm. of trional. One hour later, slept for eight hours.

March 14. The same dosage. Two hours later slept
for nine hours.

March 15. The patient asked for an increase in the
quantity of trional to make up for the diminution of the mor¬
phine. The dose was raised to one and one-half gms. She
was more restless than on the previous nights.

March 16. The dose of trional was increased to two
gms. and one of the hypodermic injections was made with a
solution of only 1-100. One hour later the patient had a
very good sleep lasting about ten hours. No discomfort on
waking.

March 17. The same doses were given with the same
result.

March 18. Two and one-half syringefuls of 1-100 solu¬
tion of morphine and two gms. trional at half-past eight
o’clock.

Slept from nine o’clock until six in the morning, but
woke frequently.

From March 19 to March 23. Patient menstruated nor¬
mally except that the flow was not very abundant. The
medication was continued as before with an average result
of seven hours sleep, coming on one and one-quarter hours
after taking the drug.

March 24. The injections were reduced to only two of
morphine 1-100 with two gms. of trional. at eight o’clock;
slept quietly from nine o’clock until six.

March 25 and 26. The same result obtained.

March 27. The dose of trional was raised to 2 \ gms.

From March 27 until April 20. When the patient volun
tarily left the hospital, the same medication was continued,
resulting in an average sleep of nine hours, coming on from
one to one and one-half hours after taking the dose.

The urine was examined every day with reference to albu¬
men glucose and haematoporphyrine. Nothing abnormal
was found at any time. According to our observation, trio¬
nal did not seem to check perspiration. No disturbance of
any of the bodily functions was noted at any time during the
treatment.

In all of these cases the urine was examined at frequent
intervals and neither sugar nor albumen was found at any

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102

Clinical Notes and Comments .

time, nor have they ever shown the dull red tinge which in¬
dicates the presence of haematoporphyrine.

The average amount of sleep obtained has been about
seven hours, and it has followed after an interval of three-
quarters of an hour to one hour after the administration of
the drug, given in wafers and followed by a hot draught.

The time required for the drug to act has, however,
varied between the extremes of fifteen minutes and six hours.
The patient is easily aroused from the sleep, but it is resumed
immediately.

In some of the cases Nos. 2,4, 11, 12, trional has seemed
to cause nightmare. Gaillard has also reported a case in
which the patient refused to take it on account of the fright¬
ful nightmares which it caused her.

We observed one case of failure in a case of cardiac dis¬
ease with defective compensation (No. 6) in which the in¬
somnia yielded to morphine. In our two hysterical cases
(Nos. 19 and 22), it had a quite marked sedative action. In
four cases (Nos. 4, 7, n, 21), there were some transitory
disturbances on waking; nausea, headache, vertigo, uncer¬
tainty of gait and noises in the ears. In case 21 the head¬
ache was, however, persistent. In case 15, trional was shown
to be superior to chloral, sulfonal, and opium ; but in case 25,
on the contrary, it was inferior to sulfonal given in the same
dose. In two cases (Nos. 27 and 28) there was noted sweat¬
ing which had not been present previously, and for which
there was no other explanation. In the first of these cases
last mentioned, a very decided improvement occurred in the
appetite.

In nearly all the cases the temperature was taken in the
evening before the medicine was taken, and on waking in
the morning. There was no difference that could be attrib¬
uted to the drug. The pulse was taken every morning and
showed no .changes after trional. Neither have we observed
any action upon the respiratory apparatus. A case of favor¬
able influence upon the digestive organs was mentioned
above, in addition to which we find note of a little diarrhoea
in case 3.

Indications for the Use of Trional.

Trional is indicated in insomnias of every variety. It
succeeds particularly well in those which are purely nervous,
with little excitement; on the other hand it is less efficacious
when the sleeplessness is caused • by a violent cough, as in a

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Clinical Notes and Comments .

103

case of tuberculosis, for example. Its action is much more
reliable in melancholia than in conditions of well-marked ex¬
citement. In delirium tremens it has seemed to give good
results, although this opinion is not shared by all the authors.
In morphinomania very good results have been obtained with
it. In general paresis the results are less favorable. Speak¬
ing broadly it may be said that trional is better suited to the
cases of those who go to sleep with difficulty, than it is to
those who find no trouble in getting to sleep but who wake
too easily. (Vogt.)

In surgical practice, it is indicated in the insomnia of ex¬
haustion from chronic surgical ailments, because it does not
depress the heart action like chloral, or is the wakefulness,
not associated with much pain, which is met with after ope¬
rations (Van Schaick.) However, we believe that pain is
not a contra-indication for the use of trional, which often
relieves, not the pain itself, but the conditions of nervous
hyper-excitation resulting from it.

It gives good results in the night terrors of childhood.

Dosage.

Trional maybe administered in single or in divided doses.
In single doses, small doses, below one gm. usually give no
result. Moderate doses, from one to two gms., act chiefly
as hypnotics in all cases of insomnia without too much ex¬
citement ; but their active sedative effect is not marked.
The method of Pelanda and Cainer seems very advisable.
They recommend giving a dose of one and one-half to two
gms. at the start, and then reducing the dose to one gm. on
the following days, in order to keep up the hypnotic effect
without any cumulative action. Large doses, from two to
four gms. should be reserved for conditions of violent excite¬
ment. Their sedative action is especially pronounced.

In Divided Doses.

By giving wafers containing 50 centigrams two or three
times per day a pretty marked sedative effect is obtained
with relatively small doses, but without hypnotic action. It
is especially in such cases and when trional is given fora
long time continuously, that its use should be suspended at'
frequent intervals, and the freedom of the bowels assured if
necessary by purgatives. As in the cases in which haema-
toporphyrinuria has appeared, the urine has always been

Vol. XVIII.—14

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104

Clinical Notes and Comments.

found strongly acid. Prof. Muller of Gratz advises that this
symptom be met by the use of large doses of bicarbonate of
soda. As a preventive measure, the alkaline mineral waters
should be given along with the trional. The dose of trional
for women should be, on an average, 50 centigrams less than
that for a man, as it has been noticed that accidents are
more common in their case.

The following, according to Claus, are the doses for
children :

From 1 month to I year,
From 1 year to 2 years,
From 2 years to 6 years,
From 6 years to io years,

2 to 4 centigrams.

4 to 8 “

8 centigms. to 1-2 gms.
1.2 gms. to 1.5 gms.

When the insomnia is associated with pain, it is desirable
to combine the trional with one centigram of morphia, or
two or three centigrams of codeia, or perhaps with phenace-
tine or acetanilide. Good results may thus be obtained,
which could not be secured by either drug alone.

Methods of Administration.

Trional may be given :

1. Suspended in cold milk, tea, or a mucilage.

2. In a hot liquid such as milk, wine or punch, in which
it is partly dissolved and partly held in suspension.

3. When the patients refuse liquids, out of suspicious
motives, it may be mixed with finely divided food or with
broth ; in the case of children, it may be given in honey or
sweetmeats.

4. By enema, the effect follows as promptly as when
given by the mouth.

But the best way is to give it in unleavened bread, fol¬
lowed immediately by a drink of 200 cc. of some hot liquid.
This should be given about a quarter of an hour before bed¬
time.

Conclusion.

1. Trional is a good hypnotic in mental disorders as well
as in the insomnias of miscellaneous origin. Its effects is
produced in from three-quarters of an hour to one hour, and
the average amount of sleep is about seven hours. The pa¬
tient sleeps quietly, is easily aronsed, and falls asleep again
promptly.

2. It seems to act upon the cerebral cortex, perhaps by
inducing a condition of ischaemia.

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Clinical Notes and Comments.

105

3. It succeeds most uniformly in the insomnias attended
by pain. When the pain is too severe, the addition of mor¬
phine or phenacetine will secure a good result.

4. It will be found to be less efficacious when there is a
condition of violent excitement, or when there is severe
cough.

5. Compared with sulfonal and chloral, it seems to equal
the former in effect and to be inferior to the latter; but it excels
sulfonal in rapidity of action (it acts in from 3-4 to 1 hour)
and has an advantage over chloral in that it does not set up
a drug habit, and that it is not depressing when given with
any degree of caution.

6. It will, therefore, be particularly useful in those pa¬
tients in whom chloral has lost its effect from long habitua¬
tion, and in patients whose condition is already one of
marked depression.

7. Small doses (1-2 gms.) seems hypnotic chiefly, and
large doses (2-4 gms.) sedative in cases showing excitement.
Divided doses are also sedative in action. The former should
therefore be given in all cases of insomnia without much ex¬
citement, and the latter when that condition is very pro¬
nounced.

8. Trional is not an analgesic.

9. At least in therapeutic doses, it has no action upon the
circulation, the respiration or the digestion. The secretions
and the heat function are only affected to an insignificant
degree.

10. Slight symptoms of intoxication (vertigo, headache,
and unsteady gait), may follow the first dose, even though it
be a small one (1 gm.) Such symptoms usually pass away
of themselves, and do not contra-indicate the use of trional,
but merely call for care in its further administration.

Dr James A. Blanchard, who for fifteen years was
superintendent of the Inebriates* Home, died Jan. 8, 1896, of
heart disease, at the institution. Dr. Blanchard was born in
Norwich, Conn., fifty-five years ago and studied in the schools
of his native town until 1858, when he took up the study of
medicine and surgery at the College of Physicians and Sur¬
geons, in New York city, from which he graduated in 1867.

Digitized by LiOOQie

io6 Clinical Notes and Comments.

He then practiced his profession in this city until 1878 and
in that year received the appointment of medical superin¬
tendent of the asylum'for the insane at Flatbush. In 1881
he was made superintendent of the Inebriates’ Home, at
Fort Hamilton, a position which he held with signal success,
linking his name so thoroughly with the institution that one
was as well known as the other.

During the war of the rebellion he enlisted in the
Twenty-third New York regiment and for valuable services
rendered was promoted to the medical corps.

He was a man of rare qualities of heart and mind and his
circle of friends was very large. His wife and a little girl
nine years of age survive him.

Fellows' Hypophosphites has become a standard medicine
in the various neurotic disorders of the times. Its value is
established in the popularity and wide demand from all parts
of the country. A trial is the best way to prove its merits.

The Arethusa Spring Water of Seymour, Conn., is an
aspirant and very prominent rival, as a rich medicinal table
water, to the famous foreign waters so much in use. Send
for some circulars.

The preparation of Tissue Phosphate by Dr. Wheeler of
Montreal is a rare and very satisfactory tonic in all cases of
brain and nerve debility. We commend it as worthy of
prolonged trial.

The question of how far Celerina will meet the demands
for relief in cases of removal of spirits has been tested in
many cases with great satisfaction. A number of physicians
have become enthusiastic in praise of its merits. There is no
doubt that it is very valuable, and should be tried in all cases.
Send to the Rio Chemical Co. of St. Louis , Mo. y for a trial
bottle.

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Clinical Notes and Comments .

107

The Treatment of Influenza or La Grippe. Anti-
kamnia Tablets (5 gr. each), No. xxx. Sig. One tablet every
two hours. *

If the pain is extremely severe, the dose is doubled until
relief is obtained. Often this single dose of ten grains of
Antikamnia is followed with almost complete relief from the
suffering. Antikamnia is preferred to the hypodermic use of
morphia because it leaves no bad after-effects; and also be¬
cause it has such marked power to control pain and reduce
fever. The author says that unless the attack is a very severe
one, the above treatment is sufficient.

After the fever has subsided, the pain, muscular soreness
and nervousness generally continue for some time. To re¬
lieve these and to meet the indication for a tonic, the follow¬
ing is prescribed:

1 $ Antikamnia & Codeine Tablets. No. xxx. Sig. One tab¬
let every four hours.

Dr. Bell also says that in Antikamnia alone we have a rem¬
edy sufficient for the treatment of nearly every case, but
occasionally one of its combinations meets special con¬
ditions. He always instructs patients to crush tablets before
taking.

Hosford's Acid Phosphate grows in value and use as it
becomes known. The demand for it expressed in hogsheads,
amounts to thousands every year. Its use as a popular drink
is a most hopeful sign of a new era of temperance coming.

Taka-Diatase , an isolated ferment in powdered form, for
the treatment of amylaceous dyspepsia. This is a new prep¬
aration of great value, put on the market by the famous firm
of Park, Davis & Co. This firm is entitled to the thanks of
the profession everywhere for their scientific skill and
enterprise.

Therapeutic use of Protonuclein : 1. Antagonism of
toxic germs of all kinds. 2. Asthenic conditions (where
the organism is below the normal physiological standard) —
restoring the vitality of tissues, stimulating and supporting

Digitized by LjOOQie

108 Clinical Notes and Comments .

assimilative nutrition. 3. As a prophylactic or preventive
in exposure to contagion or infection, in which case it either
protects the organism from attack, or greatly modifies the
virulence of the disease if attacked. Reed & Carnrick of
New York make this excellent preparation.

The Maltine tonics prepared by the Maltine Manufactur¬
ing Co. of New York city, are the most useful and practical
preparations in the market. We have called attention to
maltine with coca wine , and now desire to earnestly urge the
use of maltine with hypophosphites , and maltine with phos¬
phorus, iron , quinine , and strychnia , as most excellent tonics.
Several other preparations, equally valuable, are made by this
firm.

Battle & Co., St. Louis:

Some time ago you sent me specimens of your prepara¬
tions of Bromidia, Papine, and Iodia. Unlike many who send
out specimens, you sent an amount large enough to really
make a trial with. I had used the two first-named a little,
but having them more forcibly brought to mind, and recog¬
nizing the fact that I had them on trial, I watched their „
action more carefully. I can say that they are both elegant
and health bearing. Bromidia I used on a man verging on
mania a potu. Papine on a nervous typhoid woman, and
Iodia on a young man who had carried boils for three years
as the result of ivy poisoning. The preparations were a
decided success in every instance.

Yours truly,

E. C. Adams, M.D.

Watertown, S. D., Dec. 10, 1895.

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THE

Quarterly Journal of Inebriety.

Subscription, $ 2.00 per year.

Vol. XVIII. APRIL, 1896. No. 2.

This Journal will not be responsible for the opinions of contributors, unless
indorsed by the Association.

THE EFFECTS OF ALCOHOL ON THE CEN¬
TRAL NERVOUS SYSTEM.*

By Henry J. Berkley, M.D., Baltimore.

The subject of the pathological effects produced by the
action of alcohol, in any of its numerous forms, upon the
tissues of the central nervous system, has attracted, since
the inception of modern pathological medicine, considerable
attention, but until quite recently the results accomplished
have not been at all commensurate with the amount of
labor expended; in fact have resulted in nothing positive
beyond demonstrating fairly conclusively that the prolonged
use of alcoholic drinks extending over a period of years are
condusive to atheromatous and other changes in the blood¬
vessels, and certain ill-defined degenerations of the cerebral
nerve cells.

Attempts to acertain the effects of alcoholic drinks on
the brain of the human subject cannot be very conclusive in
their results from a microscopical standpoint, because we
are hampered by a lack of knowledge of the post-mortem

* Portion of a lecture on the effects of toxins on the nerve cell, delivered
at the Johns ) Hopkins Hospital, March 29, 1896.

Digitized by LjOOQie

I io Effects of Alcohol on the Central Nervous System.

changes that follow dissolution within a few hours, and it is
rare indeed that one can obtain pathological material from
the human subject sufficiently early to be absolutely certain
that we can definitely exclude all anatomical changes.

The finer the stains we use, the more difficult does it
become to recognize the minute histological alterations,
and after an attempt on my part to study the human brain
in alcoholism, from the standpoint of a previous knowledge
of brain cell lesions, I was obliged to abandon the attempt
until the definite lesions could be ascertained by experi¬
mental study, not that we were unable to find pathological
changes, but from an inability to interpret them, and dif¬
ferentiate between abnormal conditions and post-mortem
states.

The literature on experimental alcoholism consists of
only two articles, from the pens of Vas and Dehio, both
using the Nissl method of staining. The first-named writer
finds alterations in the chromatin structures, the finely
granular character of the nerve cell is perceptibly dimin¬
ished, and gives place to a homogeneous swelling. In
advanced cases of the alteration, the cellular protoplasm
alters its power of taking up the coloring matter, and
appears darker than usual. A shrinkage of the protoplasmic
body cannot be definitely ascertained.

The study of Dehio was never finished. He tried rapid
poisoning of animals with large doses of alcohol, and studied
its results on the Purkinje cells. Alteration in the chro¬
matin of the cells was found, with more uniform absorption
of the dye than normal, but this pathological find is far from
definite.

Nearly a year ago, owing to the kindness of Dr. Frieden-
wald of this city, who was conducting a series of experi¬
ments on the effects produced by alcohol on the animal
organism, I was enabled to procure the brains of eight rab¬
bits that had been subjected to the continued —intra vitam
— action of alcohol over a period of time varying from three
weeks to more than one year.

Digitized by LjOOQie

Effects of Alcohol on the Central Nervous System, m

They were cerebra from two series of experiments. The
first series comprising five brains had been systematically
fed daily with quantities of absolute ethyl alcohol, varying
from five to eight c. c. Death eventually took place in con¬
vulsions. The principal clinical symptoms noted were a
progressive diminution in weight, increasing torpidity, and
eventually convulsions. Nearly all the animals showed at
the post-mortem evidences of fatty changes in the heart
muscle.

The second series ‘comprised the brains of three rabbits
that had been subjected to the action of the drug in a some¬
what different manner, more closely approximating the
course taken by a man while on a debauch. The rabbits
were first fed for several days on a minimal amount of ethyl
alcohol, and after a certain tolerance had been established,
the quantity was gradually increased until it reached twelve
to fifteen c. c. of the poison given daily in a single dose.
Despite feeding and careful attention the animals emaciated
greatly, losing nearly one-half their weight, and eventually
all died, almost precisely three weeks after the beginning of
the experiment.

The material for the study obtained, it then became
necessary to find some special method of staining by which
the finer portions of the neuron, the protoplasmic dendrites,
and the substance of the axon and collaterals to their end-
apparatus could be stained with certainty. This was finally
accomplished by the addition of phospho-molybdic acid to a
silver nitrate solution, by which Muller’s fluid preparations
were impregnated somewhat after the manner of the rapid
Golgi method. Those portions of the cerebra fixed in
absolute alcohol answered perfectly well for the Nissl and
other aniline stains for the demonstration of the protoplasm
of the cellular bodies, the nuclei, and the structures of the
blood vessels.

The histological lesions in the two classes, acute and
chronic alcoholic poisoning, divide themselves chiefly by the
different characters of the vascular lesions into two groups.

Digitized by LjOOQie

112 Effects of Alcohol on the Central Nervous System.

the nerve cell lesions being of the same character in both,
only varying in amount and intensity of the alteration.

In the acute series the damage to the vascular apparatus
is exceedingly well defined. Especially in the medium¬
sized and smaller arterioles, the nuclei of the intima are
swollen, show definite alterations in their staining qualities,
and at times appear to be even necrotic. The muscularis is
greatly swollen, hyaline in appearance, has assumed new
staining qualities, and the elongated nuclei have in part dis¬
appeared from their positions. Owing to the swelling of
the middle vascular layer the Virchow lymph space has been
obliterated, and, in fact, in many places where the swelling
is intense, the adventitial layer is closely pressed against the
outer margin of the peri-vascular space. This last sheath
of the arteries does not appear to have been damaged to the
same extent as the more internal ones, its nuclei staining
better, and there being no visible tumefaction. The con¬
tents of the peri-vascular spaces, wherever the swelling of
the muscularis has not completely obliterated it, attracts
attention. In it are large quantities of a finely granular
detritus, and scattered thickly among the granular matter
lie numbers of leucocytes in various stages of degeneration
and disintegration.

Within the vessel are mingled with the red blood cor¬
puscles large numbers of leucocytes, all showing evident
signs of corpuscular alteration. Somewhat strange to note,
all these leucocytes are of the polynuclear variety, hardly
any of the mononuclear ones being visible among them.
Here and there in the arterioles and capillaries the leu¬
cocytes have aggregated into masses, and form veritable
plugs in the lumen of the vessels, and from their very closely
packed appearance must have occasioned an almost complete
stoppage of the blood-stream sometime before death. Out¬
side the walls of the arterioles the leucocytes are in places
so thickly set together that they compress the sheaths of
the vessel, and in this way have helped to retard the blood
current. Ruptures of the walls of small veins are by no

Digitized by LjOOQie

Effects of Alcohol on the Central Nervous System . 113

means infrequent, but never is the blood extravasated
beyond the sheath of the peri-vascular space into the sur¬
rounding cerebral substance.

Two factors have probably place in the damage to the
circulatory apparatus, the presence of a poisonous irritant
circulating with the blood-current, and damaging the walls,
and secondly, and not less important, the production of an
acute leucocytosis from the deteriorating action of the
alcohol on the blood-forming organs. The immense num¬
bers of leucocytes that are carried by the blood stream into
the cerebral circulation accumulate, probably, from the
atonic condition of the heart muscle and the muscular walls
of the arterial system not being able to force them through
the capillaries equally with the red-blood corpuscles by
reason of their larger size, and they accumulate in these
canals, plugs of them are slowly formed, a backward pressure
on the arteries begins, which is especially deleterious in the
already weakened condition of these vessels from the pois¬
onous effects of the drug, and eventually so great does this
pressure become that the arterial walls are greatly damaged,
and lose to a great extent their vitality.

The changes in the nerve cells seen with the aniline
stains are commensurate with the arterial ones. They
consist chiefly in alterations of the cellular protoplasm,
which now shows an increased absorption of the dye,
together with diffused staining of the chromatin particles.
The most extensive degree of cellular alteration is found
in the immediate neighborhood of greatly damaged vessels ;
where the vessels have little or no alteration of their sheaths
the cellular elements are usually sound. Nuclear lesions
are neither well marked, nor advanced.

The interesting degeneration of the protoplasmic twigs,
which occurs equally in the chronic alcoholism, will be
described under that section.

Morbid changes in the neuroglia are of interest and
moment. The ordinary support neuroglia, both along the
pial margin, and the star-rayed cells more deeply situated,
Vol. XVIII.—19

Digitized by LjOOQie

114 Effects of Alcohol on the Central Nervous System.

are unaffected by the changes in the vascular and nervous
elements. On the other hand, the vascular neuroglia shows
important changes. The cells are much swollen, the bodies
rounded, the tentacles thickened, though not spreading over
more territory than normally; altogether they appear to be
taking an active part in the process of degeneration, taking
up and removing from the tissues the detritus of the
destroyed protoplasmic twigs and stems.

Vascular changes in the chronic cases are not nearly so
pronounced as in the acute ones. The walls of the arterioles
are irregularly shrunken, and their nuclei, while not
increased in numbers, are swollen, and show abnormalties
in their staining qualities. Changes in the muscularis are
almost absent. The peri-vascular spaces are larger than in
the control preparations, and the hyaline sheath is a little
more definite than normal. In the larger arteries there is
thickening of the sheaths, and considerable focal multiplica¬
tion of the nuclei of the adventitia. In the spaces around
the vessels a few grains of hematoidin debris is occasionally
found, together with a little fine granular detritus. Miliary
hemorrhages near the pial margin of the cortex are not
infrequent.

The vascular contents attracts but little attention, there
is a rather unusual number of polynuclear leucocytes in the
blood, but, very few of these have transuded through the
walls into the outer space.

The protoplasm of the cortical nerve cells, especially
those of the psychical variety, shows insignificant departures
from the normal in the form of alterations in the chromatin,
and absorption of larger quantities of the dye, the cell stain¬
ing somewhat diffusely. Nuclear variations on the contrary
are very pronounced, and show mainly in the central
nucleolar figure, which is enlarged, roughened, and has
elongated buds projecting from its surface. The portions of
the nucleus beyond the nucleolus show diminution of the
presence of the molecular particles, in contrast to the con¬
trol preparations. In the clear karyoplasm there is a

Digitized by LjOOQie

Effects of Alcohol on the Central Nervous System . 115

decided tendency to take up more than is normal of the
aniline stain, and so marked does this tendency become,
that at times the contents of the nucleus are rendered indis¬
tinct, and it becomes much less retractile than natural.

In examining a pathological tissue by any of the silver
methods we must bear constantly before our mental vision
the fact that this method of staining is extremely apt to lead
one into error, not only from the unknown post-mortem
changes of the cerebral structures, but also from the incon¬
stancy and inequality of the staining of the elements. We
should, therefore, have always at hand a large supply of
control material, so that whenever question arises we may
have before us all variations of the normal characteristics of
the nerve cell. These variations in health are within cer¬
tain limits, and must be passed before one can say
with certainty that we have before us a pathological con¬
dition. Inequalities in staining are much more likely to
lead one into error than any amount of physiological varia¬
tion.

For the practical purposes of this examination, the
intrinsic variations in the neuron may be reduced to the
normal inequalities or varicosities in the substance of the
finer dendrites. These varicosities in the dendrons are of
comparatively infrequent occurrence, and show either as
knots at the forkings of the branches of the dendrites, or as
small irregular swellings, seldom more than one or two on
each stem, particularly at or near their terminations.
Equally with the other portions of the stems the irregular¬
ities are covered by the gemmules. This presence of the
knob-ended gemmule helps one greatly to differentiate
between normal and abnormal thickenii^g of the dendrites,
for, whenever the irritation which produces the swelling is
continued over a considerable period, the gemmulae fall off
and disappear.

After all possible allowances have been made for arti¬
facts and physiological variations in our sections stained by
the silver phospho-molybdate method, there remain a large

Digitized by LjOOQie

116 Effects of Alcohol on the Central Nervous System.

number of cells that are distinctly abnormal. The principal
lesions of the nerve cell in the alcoholic brain, to which we
would call attention, are a distinct diminution in size, dis¬
appearance of the gemmules, certain swellings of the den¬
dritic stems, roughening of the thicker processes, and also to
some extent of the cellular body, the last being caused by
shrinkage of the protoplasm.

A careful comparison of a control preparation, and one
from an alcoholic rabbit will show the following essential
differences: the cell bodies and main processes are in the
control more even and smoother, the dendrites are broader,
and the gemmules stouter and more numerous, thicker, more
feathery, apparently spreading over more lateral surface, and
are very regular in appearances, while in the alcoholic, there
is a gap here and there as if some of them had fallen off, or
had disappeared, while the processes appear to be thinned,
and have at numerous places irregular thickenings on which
the lateral buds are entirely absent.

Among the cellular layers we find a vast number of cells,
especially the pyramidal form, which show upon their pro¬
toplasmic extensions some of these tumefactions of rounded
or elliptical form. Some of them are very small, and are
only to be noticed after close search, while others are so
large as to immediately attract attention. The num¬
ber of the dendritic swellings may vary greatly, a den-
dron may be almost covered with them, or there may be only
one or two on the stem, in the latter case they are ‘usually
larger than in the former.

The process of tumefaction always appears to begin near
the free extremity of the dendron, and gradually extends
downward toward the body of the cell. The basal dendrites
are usually not so extensively involved in the degeneration
as the apical.

An essential accompaniment of the process of tume¬
faction of the protoplasm of the dendrites is the loss of the
gemmulae. The smallest pathological swelling causes an
evident decrease in the number of the.buds on the portion

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Effects of Alcohol on the Central Nervous System . 117

of the dendron affected, as the swellings increase they pro¬
gressively disappear, and when a process is filled with tume¬
factions and knots they entirely vanish, with, perhaps, the
exception of a few scattered ones situated along the least
diseased portions of the stem. In the intervals between the
thickenings the dendrites appear to be atrophied.

It would seem from our. specimens, as if the denudation
of the gemmulae and the tumefaction of the stems was the
first step in a process that eventually was to end in the entire
destruction of the cell, at least so far as its functions are
concerned, for the stumps of cells that remain can have
neither projective nor receptive faculties. It is true though
that very few of the cells show signs of advanced deterior¬
ation of the substance of the cellular body, though here and
there a neuron may be found which exhibits a more striking
degree of degeneration. The body is now greatly roughen¬
ed, and the staining of the altered protoplasmic substance is
very irregular.

Unlike the dendritic substance that of the axon shows no
decided changes, even when attached to the most degenerated
cells. The collaterals and end-apparatus of the axon is
equally uninfluenced by the degenerative process, and these
portions of the neuron have everywhere all the appearances
of health.

While the alterations of the neuron in the acute alcoholic
cases undoubtedly is due to the combined effects of the
alcohol and the disturbance of the vascular supply, the same
conditions do not wholly apply to the nerve elements in the
chronic ones. The vascular lesions are now inconsiderable,
and accordingly we must now look to the direct action of
the poison as the cause of the degeneration of the nerve ele¬
ments, acting as it does through the medium of the nutrient
supply upon the cellular protoplasm, the serous portions of
the blood permeating through the tissues, and with the ad¬
mixed alcohol coming directly into contact with the living
protoplasm of the cell, the least resistent portions, those at

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118 Effects of Alcohol on the Central Nervous System,

the greatest distance from the corpus suffering first, then
the other portions of the soft protoplasm.

Cerebellar lesions in alcoholism correspond entirely with
those in the cerebrum.

One striking feature of the degenerative process is, that
very considerable numbers of the cerebral and cerebellar cells
remain apparently intact, perhaps, it is only every third or
fourth cell that shows pronounced alterations, but this fact can¬
not militate against the conception of the degeneration as a
pathological entity from the standpoint of the numerous forms
of dementias and chronic alcoholic psycoses, for the nerve ele¬
ments of the cerebrum are intricately connected one with
another by means of their conductor-endings and the knob-
ended gemmulae, between which the dynamic forces origin¬
ating in the cell-body pass from one cell to the other over the
almost imperceptible space that is present between the two,
and thus the death of a single cell may destroy the normal re¬
lations between dozens of other cells, and in this way induce
an inco-ordination of thought and action, while the vast
majority of the cellular elements retain their histologically
normal characteristics.

Using the same methods of staining and fixing of the tis¬
sues, we have found similar lesions in the cerebra of human
alcoholics as in our rabbit series, only the lesions are less
extensive than with the animals, perhaps, only because the
human subjects had received presumably smaller quantities
of alcohol in proportion to their bodily weight than the
rabbits.

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Relation between Intemperance and Mental Disease. 119

ON THE RELATION BETWEEN INTEMPERANCE
AND MENTAL DISEASE.

By Bedford Pierce, M.D. (Lond.),
M.R.C.P. (Lond.),

Medical Superintendent of the Retreat , York.

In considering the relation between alcohofand mental
disease, the first question that arises is the extent to which
insanity is produced by alcohol. Every text-book upon
mental diseases describes a special form of insanity due to
alcoholic intemperance, independently of that acute form of
mental disorder known popularly as delirium tremens.

It is unnecessary for me to point out the characteristic
features of alcoholic insanity, even if it were easy to do so;
but I may remark that it presents no constant symptoms,
and that unless one knows the history of patients suffering
from it, there is great difficulty in distinguishing them from
those laboring under other forms of mental disease. Hallu¬
cinations of hearing in the form of “ voices ” are common ;
also delusions of suspicion, and such patients may be very
dangerous ; in other cases they are profoundly depressed,
with a strong tendency to suicide. A large proportion of
those “ found drowned ” and reported in the press are, if
their history were known, chronic alcoholics, and it is note¬
worthy that no less than 20.8 per cent, of the suicidal male
patients admitted into our asylums give a history of intem¬
perance. Profound mental enfeeblement is the termination
of almost all cases that do not recover. Alcoholic insanity,
however, when not of long standing, is one of the more
curable forms of mental disorder. As one would expect,
total abstinence from alcohol is essential if the recovery is
to be complete. I have no sympathy with a treatment that
prescribes for such patients “ a hair of the dog that bit

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120 Relation between Intemperance and Mental Disease . 4

them/’ Two thousand three hundred and sixty-five patients
suffering from alcoholic insanity have been annually admit¬
ted into English asylums, taking the average of the last five
years. This gives a percentage of the total admissions of
14.2 per cent. There is, however, a great difference if we
distinguish between the sexes in the incidence of alcoholic
insanity, since drink was the cause in no less than 20.8 per
cent, of the males admitted, and but 8.1 per cent, of the
females.

These figures are obtained from returns furnished to the
Commissioners in Lunacy by the medical officers of asylums,
and are published in the Blue Book for 1894.

If private patients (those whose friends are able to pay
for their maintenance) are considered apart from pauper
patients, the percentage is very slightly reduced; and we
may safely conclude that this cause of insanity operates to
almost the same extent in the middle classes as in the lower
classes of our population.

In the Retreat the numbers are too small to allow of
any reliable comparison. Including all cases in which alco¬
hol may be a contributing cause of the mental break-down,
I find that out of 40 males admitted during the past three
years, 10 gave a history of alcoholism; while out of 58
females, there were but 8 cases. Thus my cases give a
total percentage of both together of about 18 percent.,
which, so far as they go, corroborate the figures given in the
Blue Book, as allowance should be made for the fact that I
include patients whose attack was accelerated, but not
entirely caused, by alcoholic excesses.

Dr. Clouston, of the Royal Edinburgh Asylum, gives the
percentage of admissions during fifteen years as 16.4 per
cent., though during the influenza years there was a sudden
increase to 26 per cent.

Exaggerated statements of this question are, I regret to
say, made; but it would not be far wrong to conclude that
from 14 to 18 per cent, of the cases of mental disease occur-

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Relation between Intemperance and Mental Disease . 121

ring in Great Britain are due in large measure to alcoholic
intemperance.

The mental ruin produced by alcohol is in no way pro¬
portionate to the 2,000 unfortunate perspns who, from this
cause, find their way into our asylums. Everyone is
acquainted with men and women whose mental powers are
so shattered by long-continued indulgence in drink that they
have reached the borderland between sanity and insanity,
even if it be not overstepped.

These subjects of chronic alcoholism may have entirely
lost the power to abstain from drinking, they may have
gradually allowed their families to become penniless, and
their children to lack the common necessities of life; their
character may have so altered for the worse that it is obvi¬
ous to everyone that they are almost different persons, —
thoughtless and selfish instead of kind and affectionate.

I do not propose to allude to the pressing need for
further legislation to obtain increased powers for restricting
the liberty of habitual drunkards, nor to the urgent call for
inebriate homes for the poorer classes; to which I may add
the need for the imposition of penalties upon those who know¬
ingly supply drink to persons notoriously of intemperate
habits, since these matters are outside the scope of my
paper. I wish, however, to emphasize the fact that alcohol
does incalculably more harm in producing mental degenera¬
tion in the many who are never placed under care, than in the
few who find their way into asylums.

There are two forms of chronic alcoholism which, as a
rule, can be distinguished; in one the indulgence is more
or less constant, and in the other it occurs in periodical out¬
bursts. In the former there is often considerable enfeeble-
ment of mind or other signs of mental deterioration, often
without actual drunkenness at any time; so that the patient
may be quite unaware of the change and his relatives even
may be ignorant of the true cause. It is one of the most
striking features of alcoholic intemperance that, in both
acute and in chronic cases, the subject does not rightly appre-

VOL. XVIII.— 20

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122 Relation between Intemperance and Mental Disease .

ciate his condition. This greatly adds to the difficulty of
treating such patients.

The other variety of chronic alcoholism is paroxysmal in
character, and to it the name “ dipsomania ” has been
given. It consists of a craving for stimulants which over¬
masters the subject from time to time when he or she gives
way to an outburst of drunkenness. These patients usually
suffer less mental deterioration than the habitually hard
drinker.

These forms of chronic alcoholism cannot, however, be
sharply defined, and many cases are intermediate between
these extremes.

In dealing with the effects of alcohol upon the individual
in producing mental disturbance, I have begun with the
more chronic and deep-seated affections, and have yet to
mention two acute disorders produced by this agent.

Delirium tremens, acute alcoholic delirium, is a condition
of profound mental disturbance which occurs after a drink¬
ing bout, and frequently when some physical disease has
lowered the vitality of the patient. It is characterized by
restlessness and excitement, and hallucinations of sight
(the seeing of creeping things, etc.).

Delirium tremens is a very grave complication of disease
and may render highly dangerous some ailment which other¬
wise might have been in no way serious.

Besides this, a form of acute mental disorder of longer
duration {mania a potu) is described by alienists as distinct
from chronic alcoholic insanity.

Besides the various mental disturbances already men¬
tioned, I must also point out that the deleterious effects of
alcohol are not confined to the individual, and that there is
overwhelming evidence to show that the children of intem¬
perate people inherit a tendency to intemperance or some
form of nervous disease.

Modern writers on heredity, Weissman and his school,
have attempted to demonstrate that acquired characters are
not transmitted to the offspring. I am satisfied that this

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Relation between Intemperance and Mental Disease . 123

does not apply to acquired alcoholic intemperance, and doubt¬
less Weissman would not teach that a definite poison could
be imbibed by a parent without injury to the offspring, and
would probably protest against his biological dictum being
carried into the sphere of pathology. Be that as it may, it
would be easy to quote a number of authors to show that
alcoholism in 'parents is very prejudicial to their descend¬
ants. Thus are the sins of the parents visited upon the
children. The offspring of such parents may either be pe¬
culiarly susceptible to the influence of alcohol, or may inherit
a mental instability rendering them easy victims to it, or the
inherited defect may be manifested in a tendency to insan¬
ity, epilepsy, or some other form of mental disorder.

There is, moreover, very strong evidence to show that
drunkenness in parents is one of the most frequent causes
of idiocy or imbecility in children.

Dr. Legrain, in a recent work upon “ Social Degenera¬
tion and Alcoholism/' has published an account of the de¬
scendants of 215 drunkards that he personally has traced.
This work shows conclusively that in such families a very
large number of the children die young, and that the families
rapidly die out; that epilepsy, insanity, and other nervous
disorders are extremely common.

Before leaving this part of my paper, it may not be out
of place to express the opinion that I consider the influence
of alcohol upon the brain of infinitely greater importance
than its influence upon the circulation or upon other parts
of the body.

In England it is true that we have heard of the watering
of geraniums by diluted solutions of alcohol, and of attempts
to accustom water-fleas to living on weak spirit and water,
and we hear that neither geraniums nor water-fleas flourish.
All this, however, is remote from the problem in hand, and
the skeptical person is not convinced by deductions drawn
from such experiments. The work done by Prof. Kraepelin
and his pupils in Heidelberg promises to be of very great
importance.

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124 Relation between Intemperance and Mental Disease.

Kraepelin has summed up his conclusions as to the ac¬
tion of alcohol in his Psychologische Arbeiten> Band I, p.
83. He states that experiment has shown that the idea that
alcohol strengthens has arisen from self-deception. Alcohol
only facilitates the discharge of motor impulses, and does
not make them more powerful. If there is any strengthen¬
ing effect, any increase of power, it is very transitory, and
is quickly followed by a pronounced diminution, which takes
some time to disappear. He goes on to say :—“ Moreover,
the powers of conception and judgment are from the begin¬
ning distinctly affected, although we perceive nothing of it.
The actual facts are exactly the opposite to the popular be¬
lief. I must confess that my own experiments, extending
over more than ten years, and the theoretical deductions
therefrom, have made me an opponent of alcohol.”

The relation between intemperance and mental disease
is, however, a reciprocal one, and not only is drunkenness a
cause of insanity, but mental disease is a cause of drunken¬
ness.

This latter aspect of the question I propose briefly to
discuss.

Consider in the first place the case of a man in the early
stages of an attack of mental disease. The disease in ques¬
tion may be almost of any kind, characterized by either ex¬
citement or depression ; but for our purpose we will assume
the attack is one of simple mania, the leading features of
which are deficient self-control and lack of judgment, excita¬
bility, talkativeness, and usually restlessness and inconstancy
of purpose. Such a patient becomes an entirely altered
man, and among other changes we may find that he has com¬
menced to drink freely, and perhaps for the first time in his
life is intemperate. The early stages of such a mental at¬
tack are insidious, and it may not be for a week or two that
the patient's relatives recognize the actual unsoundness of
mind, and take the necessary steps to ensure proper treat¬
ment. In looking for an explanation of the attack, what is
more likely than that the whole may be ascribed to the

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Relation between Intemperance and Mental Disease. 125

unaccustomed indulgence in drink ? And thus the case may
be considered primarily alcoholic, when the alcoholic indul¬
gence was really secQndary to the mental disorder. My
point is this, that in the course of acute mental disorder it
is not rare to find that patients hitherto abstemious may be¬
come very intemperate, owing to the loss of self-control
produced by the disease. It is, however, certain that this
influence of mental disorder is not limited to acute dis¬
ease.

If we consider the extensive evils which, during the past
few years, have been produced by influenza, we shall find
that one of the most common results has been a more or
less defined mental and nervous disorder. Numberless peo¬
ple have never been the same since their attack, and not a
few have become actually insane on account of this obscure
and insidious nervous poison. It may, I think, be fairly
contended that intemperance has also been caused in the
same way. We know that there was an extraordinary in¬
crease of spirit drinking, coincident with the appearance of
influenza among us. Doubtless much of this was due to
habit or a false belief as to the efficacy of spirits in combating
the disease; but I also think there is good reason to be¬
lieve it was due in large measure to the depression produced
by the disease itself.

There are other forms of nervous disease which may con¬
tribute to the production of intemperance, notably hysteria,
epilepsy, dyspepsia; and several well-authenticated cases
are recorded in which habitual drunkenness dated, from
injury to the head. Thus in some obscure way a shock or
actual injury to the brain may be the proximate cause of
drunkenness in persons who have previously been tem¬
perate.

If we examine the family history of chronic alcoholic
patients, we shall find they present an unusual number of
relatives suffering from some form of mental disease. And,
indeed, in cases where there is a history of alcoholism in the
parents, a further inquiry may show an insane inheritance.

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126 Relation between Intemperance and Mental Disease.

The following case quoted by Legrain will illustrate this
point: —the patient, an epileptic imbecile, was one of a family
of sixteen, ten of whom died in childhood ; one sister, who
was hysterical, had nine children, many of whom died in
convulsions. One brother of the patient was feeble-minded
and deaf, one brother was epileptic, and a brother and sis¬
ter are described as very nervous. The mother of these
children was alcoholic and hysterical, the father was an in¬
veterate drunkard, and two paternal uncles were drunkards.
The paternal grandparents, however, were not intemperate,
but the grandfather was weak-minded and the grandmother
hysterical.

This case illustrates the conclusion which I believe we
can safely draw, viz.: that alcoholism tends to arise in fam¬
ilies that are unstable, and that this instability is an inherited
neurotic condition that may be manifested in many different
ways.

It may serve to emphasize this point if I quote the opin¬
ions of a few authorities :

Dr. Clouston. —“ Excessive drinking and mental disease
are closely connected hereditarily in many cases. The
children of drunkards often become insane, the children of
insane people still more often drunkards.”— (Momingside
Reports , 1889.)

Dr. Maudsley. —“ The neuropathic nature of dipsomania
is further attested by these facts ; first, that it is commonly
found to own a morbid, nervous inheritance, such as ances¬
tral insanity, epilepsy, or drunkenness; and, secondly, that
it is sometimes acquired as the sequel of an injury to the
head, or of a sunstroke, or of a regular attack of acute insan¬
ity.”— (Pathology of Mind, 2 d Ed., p. 501.)

Dr. Legrain found heredity in 63 out of 103 cases of
drunkenness. He also says “the great majority of drinkers
are predisposed, disordered, and defective. The drinker is
almost overwhelmed by a number of cerebral affections in
the family with which he is connected by the close band of
morbid consanguinity. Excess in drinking is only one of

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Relation between Intemperance and Mental Disease. 127

the numerous characteristic symptoms of mental ruin.”—
( Tukes Dictionary of Psychological Medicine, p. 65.)

Dr. Blandford. — “ Early habits of drinking are also fre¬
quently contracted by weak-minded people, and we con¬
stantly find that habitual drunkards, as well as dipsomaniacs,
are the offspring of insane or epileptic patients.” — {Insanity
and its Treatment, p. 161.)

Dr. Savage. — “ Drinking may be an early symptom of
insanity. It may be a direct inheritance, or it may be a
result of neurotic inheritance.” — ( Insanity and Allied
Neuroses, p. 421.)

My own results, in so far as they go, entirely corroborate
the opinion that a neurotic inheritance (by which I mean
the inheritance of a tendency to epilepsy, insanity, hysteria,
or other kindred nervous diseases) is a predisposing cause
of inebriety. Out of 18 alcoholic patients, 8 presented a
history of mental disease, 3 a history of alcoholism in the
family.

One other point in the inheritance of a tendency towards
drunkenness is the increased susceptibility to the influence
of alcohol that certain members of a neurotic stock possess.
In its cruder forms this is seen by the production of pro¬
found intoxication by very moderate quantities of alcohol.

To sum up, I think there is no escape from the conclu¬
sion that, on the one hand, alcohol does an incalculable
amount of harm quite independently of any question of in¬
herited failings or even acquired predisposition ; and, on
the other hand, in very many cases of habitual drunkenness
there exists a decided inherited' proclivity to alcoholic in¬
temperance or other manifestation of nervous instability.

One conclusion is inevitable in considering this question,
viz., that members of unstable and neurotic families should
totally abstain from alcoholic beverages. Yet we all know
of cases where, in spite of every warning, this necessary
means of avoiding calamity is entirely disregarded. But if
we reflect, we may see that this reckless conduct is not
necessarily due to willful choice of a dangerous path, but it

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128 Relation between Intemperance and Mental Disease .

may be due either to inherited and imperative desire for
self-indulgence, or to some innate defect of judgment.

Everyone with experience in mental disease knows how
ill-defined is the boundary between sanity and insanity ;
and the study of mental disorder in the few within and the
many without asylum walls profoundly influences our
opinions upon responsibility for errors of conduct. It
makes everyone charitable to recollect how poorly equipped
mentally, as well as physically, such a large number of
mankind begin life, and how ill able they are to surmount
its difficulties. In reflecting upon the causation of drunken¬
ness, the same charitable considerations must influence us.

Alcohol seems to have a special affinity for the nerves of
the extensor muscles of the legs. Why should the terminal
portions of the peripheral nerves be first affected ? Is it
because they cover a much larger area than when collected
into bundles, and so are more exposed to the poison circu¬
lating in the capillaries, and partly because they are farthest
removed from the nerve cells, on the energy radiating from
which their health depends ?

The selective power of alcohol is also remarkable, for
the sensory nerves and cells causing much disturbance long
before paralysis comes on. Is this nerve intoxication which
in most cases is found to be a breaking up of the medullary
sheath of the nerve in segments ? Wide-spread central nerve
and muscular degeneration follow from alcoholic poisoning,
but whether this is nerve intoxication, nerve degeneration,
or nerve inflammation, is not clear.

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Pulmonary Tuberculosis , etc.

129

PULMONARY TUBERCULOSIS IN THE SUBJECTS
OF ALCOHOLIC NEURITIS.

By T. N. Kelynack, M.D., (Viet.), M.R.C.P. (Lond.),

Pathologist, Manchester Royal Infirmary; Demonstrator and Assistant Lec¬
turer in Pathology, The Owens College.

Under the heads of alcoholism and tuberculosis, the
pathologist has to group a considerable number of lesions,
which, while presenting different macroscopic and micro¬
scopic characters, are yet in all instances due primarily
either to the toxic influence of the chief product of the
growth of yeast organisms, or the toxic bodies associated
with the development of the tubercle bacillus. In both
cases we have to deal essentially with the results of a tox-
aemic condition.

Modern observations have clearly shown that the devel¬
opment of certain micro-organisms in the body may be mod¬
ified by the presence of other organisms or their products.

And, still further, the results of recent treatment by so-
called immunized serum and animal extracts seem to indi¬
cate the great probability that some, at least, of the as yet
but little known conditions, which we speak of collectively
as “predisposition,” are closely dependent on chemical in¬
fluences which may not only be recognized but possibly con¬
trolled.

A consideration of such facts as these leads one to ask
— Is there any reason to believe that chronic alcoholism
predisposes to tuberculosis ?

An impression exists among a large section of the pub¬
lic, and indeed, is supported in some medical quarters, that
habits of alcoholic excess are antagonistic to, and even pre¬
ventative against, tubercular disease.

Payne, a few years since in the Discussion on Chronic
Vol. XVIII.— 21

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130 Pulmonary Tuberculosis in the

Alcoholism at the Pathological Society of London, stated
that: “With regard to the influence of alcohol on the pro¬
duction of tubercle, the utmost divergence, and indeed con¬
tradictory opposition of opinion, prevails. Huss found tuber¬
cular phthisis to be rare in drunkards, and that has been the
general conclusion drawn from post-mortem observations.
It has even been thought that drinking freely checks the
progress of phthisis, but of this I can find little evidence.
On the other hand, the more general impression is that alco¬
holism is a frequent cause of consumption/ 1 Payne goes on
to add: “ On this disputed point we must appeal to the
methodized experience of those who have special opportuni-
tfes of observation/ ,

Adopting this suggestion of Dr. Payne, 1 have ventured
to indicate very briefly our experience in the Pathological
Department of the Manchester Royal Infirmary during the
last three years, limiting myself, however, at the present
time to a consideration of those cases of alcoholism in which
the chief feature was that of “paralysis.” In these cases
the history and clinical features conclusively established the
fact of the long-continued alcoholic poisoning.

Eight fatal cases of alcoholic paralysis have been ex¬
amined in the Pathological Department of the Manchester
Royal Infirmary since October 28, 1892, and in no less than
seven, pulmonary tuberculosis was found.

The following abstracts of our notes will briefly indicate
the chief features :

Case i. —Chronic Alcoholism ; Hepatic Cirrhosis; Multi¬
ple Neuritis; Acute Ptilmonary Tuberculosis; Gangrenous
Colitis with Perforatioii ; Acute Peritonitis.

Fanny G., aet. 45, was admitted under Dr. Dreschfeld,
July 30, 1892. Well marked history of chronic alcoholism;
typical symptoms of peripheral neuritis ; much gastrointes¬
tinal disturbance, with vomiting during last month; recent
development of symptoms of acute miliary tuberculosis of
lungs.

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Subjects of Alcoholic Neuritis. 131

Autopsy. — Much wasted, sallow-looking middle-aged
female.

Lungs: Both extremely congested. Numerous recent
scattered tubercles in lower left lobe. No tubercles in
right, which was emphysematous and deeply pigmented.
Weight: right, 11 oz. ; left, 15 oz.

Heart: Six ounces, small, myocardium soft, flabby. Peri¬
toneum: Semi-fluid faecal matter in abdominal cavity.
Stomach : Acute gastritis. Intestines : Small, intensely con¬
gested. Large localized gangrenous enteritis in central por¬
tion of transverse colon, with distinct perforation. Liver
small, 39 oz., distinctly “cirrhotic.” Spleen: 2^oz., much
congested. Kidneys: Fairly normal. Bladder: Walls
thickened, much inflamed, and in places seat of phosphatic
deposit.

Case 2.— Chronic Alcoholism ; Multiple Neuritis ; Car¬
diac Dilatation ; Pulmonary and Intestinal Tuberculosis.

Mary T., aet. 57, was admitted under Dr. Steell on March
29, 1893. On admission presented well-marked symptoms
of peripheral neuritis. Quickly developed delirium of “alco¬
holic” type, and died April 4th.

Autopsy. —Short,* well-formed, middle-aged female.

Lungs: Both much congested ; patch of “ healed phthi¬
sis ” at left apex; numerous areas of recent caseous pneu¬
monia throughout greater part of upper lobe. No distinct
tubercle in right lung.

Heart: 8 oz., cavities of left side dilated. Intestines:
Numerous tubercular ulcers along ileum and ileo-caecal valve.
Liver, 52 oz., slightly cirrhotic and markedly fatty. Spleen :
2 oz., soft, congested and pulpy. Kidneys : Both congested,
but otherwise apparently normal. Brain : Congested. Ir¬
regularly triangular patch of red softening in left lenticular
nucleus. Membranes congested and somewhat thickened.

Case 3.— Chronic Alcoholism ; Pregnancy ; Normal Par -
turition; Fatty Degeneration of Myocardium ; Steatosis of
Liver; Multiple Neuritis; General Anaemia; Pulmonary
Tuberculosis .

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132

Pulmonary Tuberculosis in the

Ellen W., aet. 40. Admitted under Dr. Harris, February
10, 1894. Very marked alcoholic history; said to have
been in the habit of taking a bottle of whisky daily. Had
been very weak and pale for twelve months. Was confined
six months ago. On admission, characteristic aspect of
alcoholic paralysis. Intense general anaemia. Very feeble
action of heart. Patient died suddenly day after admission
from cardiac syncope.

Autopsy .—Body, that of wasted, dusky-looking, middle-
aged female.

Lungs: Right: Whole lung anaemic and oedematous.
Numerous patches, chiefly in middle lobe, of tubercular
caseous pneumonia. Slight puckering at apex, but no dis¬
tinct indication of old tubercle; left area of complete con¬
solidation of tubercular caseous pneumonia. The cheesy
area was breaking down in center, forming an irregular
cavity which extended to the pleura. Left apex presented
no evidence of old phthisis, and lower lobe free from macro¬
scopic tubercles.

Pleurae: The left pleura in greater part of visceral
pleura thickened by recent deposit of inflammatory lymph
which could be readily detached. On posterior part nu¬
merous, small, raised, white, glistening tubercles. Heart :
Enlarged, flabby ; much sub-epicardial deposit of fat; myo¬
cardium, soft, friable, yellowish-brown color, and presented,
particularly in region of papillary muscles, distinct “ tabby-
cat ” striation. Peritoneum: No tubercle. Stomach and
intestines: Anaemic. Liver: Old perihepatetic adhesions;
weight, 100 oz.; general steatosis; slight cirrhosis. Spleen:
4i oz. Kidneys: Finely granular.

Case 4. —Chronic Alcoholism ; Chronic Pleurisy and Per¬
itonitis ; Multiple Neuritis ; Acute Pulmonary Tuberculosis .

Isabel C., aet. 32, housewife, admitted under Dr. Dresch-
feld, May 28, 1894. Had been a “secret drinker” for along
time. On admission characteristic symptoms of multiple
neuritis. Little or no improvement, and then development
of marked pulmonary phthisis, leading to death on July 23.

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Subjects of Alcoholic Neuritis. 133

Autopsy . — Middle-aged, much emaciated female; bed¬
sores.

Lungs: Both much congested, and studded with tuber¬
cular nodules.

Pleurae: Extensive firm, fibrous adhesions. Heart:
8 oz., and apparently normal. Peritoneum: Old peritonitis,
with much matting together of intestines. Liver: 44 oz.,
slightly cirrhotic. Kidneys: 5 oz. each, slightly granular
surface. Cord : No macroscopic changes.

Case 5. —Chronic Alcoholism; Fatty Liver; Multiple
Neuritis ; Pulmonary Tuberculosis ; Paralysis of Diaphragm.

Margaret C., admitted under Dr. Steell, August 1, 1894.

History of steady drinking for last fifteen years, during
which she had very little food.

On admission presented characteristic symptoms. Com¬
plete paralysis of lower extremities. Tendon reflexes absent.
Muscular hyperaesthesia disappeared from the calves, but
continued in the thighs. For the last few days before death
the diaphragm was almost completely paralyzed. Death
from respiratory failure occurred on October 19, 1894.

Autopsy .—Well-formed, somewhat wasted, middle-aged
female. Foot dropped on both sides, with drop of big-toe
most marked.

Lungs: Right, more or less crepitant throughout, con¬
gested, slightly oedematous and with several, small, gray
irregular foci of consolidation, especially marked in upper
lobe, and evidently tuberculous. Left upper lobe almost
completely consolidated by tubercular pneumonia. Consid¬
erable fibroid induration, caseation, and softening with dis¬
tinct cavitation. Lower lobe also congested, oedematous,
and studded with recent tubercle. Pleurae: Slight adhe¬
sions. Bronchial Glands: Enlarged and evidently tuber¬
culous.

Pericardium: Normal. Heart: Small; weight, 8£ oz.;
much sub-epicardial deposit of fat. Myocardium: Soft,
flabby, friable, and seat of considerable degenerative changes.

Peritoneum: Normal. Stomach: Congested and coated

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134 Pulmonary Tuberculosis in the

with mucus. Liver: 56 oz. No cirrhosis, but slightly fatty.
Spleen: Normal. Kidneys: Normal. Brain: Apparently
normal; vessels, healthy. Spinal Cord: Presented no dis¬
tinct macroscopic lesions. Phrenic Nerves: Microscopically
found to be in condition of marked neuritis.

Case 6 . — Chronic Alcoholism; Fatty Liver; Multiple
Neuritis ; Pulmonary Tuberculosis .

Charlotte A., aet. 41. Admitted under Dr. Leech, Feb¬
ruary 5, 1895. Alcoholic history. Had cough three weeks
before admission. Six months ago said to have spat blood.
For last month had severe pains in legs and progressive
weakness in limbs. On admission, characteristic signs of
extensive neuritis in lower extremities. Also much cerebral
disturbance, chiefly in form of delusions. Extensive dull¬
ness over upper part of right lung, with bronchial breathing
and rales. Temperature high and irregular. On February
12th, shortly before death, paresis of diaphragm was noted.

Autopsy. — Well-formed, wasted, anaemic, middle-aged
female. Foot drop on both sides.

Lungs: Both seat of extensive tuberculosis. Right most
involved, upper half being converted into pigmented fibrous
tissue, in which were numerous foci of caseation and many
large cavities. Recent caseous nodules occupied upper part
of lower lobe, in several places breaking down into cavities.
Left lung presented caseous areas and several small cavities.
Pleurae: Extensive adhesions especially marked on right side.

Pericardium: Contained quantity of serum. Heart:
Much sub-epicardial deposit of fat. Myocardium: Soft and
flabby. Peritoneum: No tubercles, but slight adhesions in
neighborhood of liver. Stomach: Dilated, congested, and
with hemorrhages in mucous membrane. Intestines: Ap¬
parently normal. Liver: Much enlarged; weight, 68 oz.,
smooth, soft, friable, yellowish-pink color, no cirrhosis.
Spleen: Normal. Kidneys: Normal. Uterus: Apparently
parous. Brain: Presented no gross lesion. Dura: Adher¬
ent to scull cap. Pia-Arachnoid: Thickened and opaque,
and with considerable sub-arachnoid oedema.

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Subjects of Alcoholic Neuritis . 135

Case 7. — Chronic Alcoholism ; Multiple Neuritis ; Acute
Pulmonary Tuberculosis.

Gertrude D., aet. 24, single, barmaid, admitted under Dr.
Steell, June 6, 1895. Distinct history of alcoholism. Had
been in the habit of taking very large quantities of alcohol,
in various forms, daily, for a considerable time. Three weeks
before admission, first noticed weakness in lower extremities.
Had cough and expectoration for some time.

On examination, extensive paresis of extremities ; unable
to stand; grasp very feeble; anaesthesia of hands; numbness
of fingers; marked muscular hyperaesthesia; inability to
hyperextend wrist ; considerable pain in legs ; characteristic
dropped attitude of toes and feet; knee-jerks absent. Paraly¬
sis of diaphragm followed ; temperature irregular—hectic
type; cough and expectoration became marked. On June
17th, tubercle bacilli found, but no very distinct physical
signs of phthisis detected in lungs up to a few days before
tubercle bacilli were found. The course of the phthisis was
exceedingly acute; she rapidly became more emaciated, her
cough became more distressing, and she died August 18th.

Autopsy. —Well-formed, wasted, anaemic young female;
extremities especially thin, with extreme atrophy of muscles
of hands; well-marked drop of toes and feet.

Lungs: Right: Extensive tuberculous consolidation,
with commencing cavitation in upper lobe. Left: Exten¬
sive, diffuse, and apparently recent tuberculosis; apex con¬
verted into huge cavity; numerous small cavities throughout
greater part of lung. Pleurae: Left pleural cavity obliterated
by pleuritic adhesions; much matting between left lung,
chest-wall mediastinal tissue, and sternum.

Pericardium: Adherent, externally, to left pleurae and
adjoining structures. Heart: Slightly enlarged. Myocard¬
ium : Soft, flabby, friable, and evidently the seat of exten¬
sive degenerative changes. Peritoneum: Normal. Stomach
and intestines: Congested. Liver, spleen, and kidneys;
Congested, but otherwise presenting no gross lesions.
Ovaries : Normal. Uterus : Nulliparous.

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136

Pulmonary Tuberculosis in the

Without entering fully, at the present time, into the
pathology of this striking association of tuberculosis with
alcoholism, attention may be drawn to the following points
brought out in these few Manchester cases:

(1) Number and Proportion of Cases. — As above indi¬
cated, post-mortem examinations have been made at the
Royal Infirmary on eight cases of multiple neuritis of alco¬
holic origin during the last three years. Pulmonary tuber¬
culosis was present in seven. This gives a percentage of
over 87.

(2) Sex. —All the cases were females.

( 3 ) Age. —The average age was 39. The oldest subject
was said to be 57, the youngest 24.

(4) Associated Active Tuberculous Lesions .—In only one
case were there distinct tubercular lesions elsewhere than in
the lungs, and then the intestines were involved.

(5) Old Tuberculous Lesions .—In one case there was an
old tubercular patch at the apex, but here it was doubtful
if infection was not from without rather than from this
“latent,” or so-called “healed” focus.

(6) Extent of Pulmoiiary Tuberculosis. —In five cases
both lungs were more or less involved. In two the left was
the only one showing any distinct tuberculous process.

(7) Duration of Phthisis. —The duration of a tubercu¬
lous process in the lungs is often difficult to estimate. Judg¬
ing from the history and the character of the lesions, it
appeared to have run a very rapid course in at least three of
the cases. In four it seemed to have lasted for several
months. One is stated to have “ spat blood ” six months
before her death. Another had had “cough for some
time.”

(8) Character of the Phthisis. —In one case the infection
was evidently recent, and one lung only was studded with
small tubercles. In two there was more or less extensive
caseou§ pneumonia. Four presented evidences of softening
and cavitation. In two of these four the lungs were also the
seat of considerable fibrosis.

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Subjects of Alcoholic Neuritis .

137

In drawing attention to the common occurrence of tuber¬
culosis in these Manchester cases of alcoholic paralysis, I
would take this opportunity of pointing out that the liability
of the subjects of alcoholic paralysis to phthisis, although
definitely recognized by Ross, Dreschfeld, Finlay, Gowers,
Payne, and other well-known authorities, does not seem to
be so clearly acknowledged in most of our text-books of
medicine as appears desirable.

Sir Benjamin Ward Richardson and others have gone so
far as to describe a distinct form of phthisis as occurring
among hard drinkers.

Professor DelSpine has also shown that drunkards are
peculiarly liable to attacks of pulmonary congestion, which,
under certain circumstances, may give rise to a pneumonia
or haemorrhagic consolidation of large tracts of the lungs
which may afford the tubercle bacillus a suitable soil for
further development.

The evidence of these few cases will, I venture to think,
tend to show that the conditions met with in chronic alco¬
holism, at least in the form of “alcoholic neuritis,” may
strongly predispose to pulmonary tuberculosis of a progres¬
sive and fatal character.

Such an admission must of necessity have considerable
influence in directing our diagnosis, guiding our prognosis,
and indicating lines of treatment.

A consideration of the above cases seems to warrant the
*

following conclusions:—

(1) The subjects of alcoholic paralysis are peculiarly
liable to pulmonary tuberculosis.

(2) A recognition of this fact is of considerable impor¬
tance in arriving at an early and complete diagnosis, and in
forming a reliable prognosis.

(3) It is desirable to treat cases of alcoholic paralysis
in special hospitals, in country homes, or in healthy private
houses, rather than in the almost unavoidably tubercle-con¬
taminated wards of a general hospital.

Vol. XVIII.—22

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138

Pulmonary Tuberculosis , etc.

(4) The necessity for immediate removal of all alcohol
from these cases and its replacement by nutritious diet.

(5) The careful avoidance of causes leading to, and the
necessity for early treatment of, all catarrhal conditions of
the respiratory passages and congested states of the lungs.

The deaths from alcoholism in Stockholm amount to 90
per 1,000, which is the highest rate in the world.

Habitual Offenders in Scotland. —The Depart¬
mental Committee on Habitual Offenders in Scotland have
drawn up a unanimous report, which is now published in a
blue-book. On the subjects of retreats for habitual inebri¬
ates the committee make recommendations practically iden¬
tical with those made by the English Departmental Com¬
mittee of 1892, with certain additional recommendations.
The inebriate of the police court would be provided for by
the “ Labor Settlement,'” to which he would find his way as
an ordinary habitual offender. The additional powers which
the committee suggest would provide for the compulsory
committal of habitual inebriates within the meaning of the
Act of 1879, at the instance of their friends, if they could
support them, and at that of the Procurator-Fiscal, at the
public cost, in cases where their conduct, though not such
as to bring them within the category of habitual offenders,
was sufficiently objectionable to render them a public
nuisance. The definition of habitual drunkard should be
extended to cover persons suffering from the abuse of opium
and other drugs as well as alcohol.

There are in the Patent Office at Washington eleven
hundred and thirty-seven different patents taken out for
methods and devices for the manufacture of alcohol.

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Hypnotism in the Management of Inebriety. 139

HYPNOTISM IN THE MANAGEMENT OF
INEBRIETY.*

By T. D. Crothers, M.D.

Superintendent Walnut Lodge Hospital , Hartford , Connecticut .

The impression that the continuous use of alcohol is
followed by hyperesthesia and increased sensitiveness and
susceptibility to the surroundings is not true, only in ex¬
ceptional cases. All inebriates who use alcohol, opium, or
other narcotic drugs, have diminished susceptibility and
impaired sensory activities, extending from slight defects to
general paralysis, not only of the functional but organic
activities, and extending to the entire organism.

The inebriate is a neurotic, and irrespective of all first
causes suffers from starvation and poisoning. The power of
control, of reason and discernment, is defective, and beyond
all outside influences is swayed by the unknown impulses of
a degenerate and defective organism. The power of a
dominant idea lasts only as long as it is not in sharp conflict
with the morbid impulses of degenerative process.

The neuroses of inebriety is practically paralysis, not of
one part of the body, but of the entire organism. If the
hypnotic state is pathologic, and the three special phases,
lethargy, catalepsy, and somnambulism, are common symp¬
toms, it is clearly possible that the narcotic effects of these
drugs may favor these conditions. But in reality the
lethargy and catalepsy from poisons introduced from with¬
out, and formed within the body, are controlled by conditions
that are largely unknown and unforeseen. From inference
it seems clear that any defect or disease of the nervous

* Read in the section on neurology and medical jurisprudence at the forty-
sixth annual meeting of the American Medical Association, at Baltimore, Md.,
May 7-10, 1895.

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140 Hypnotism in the Management of Inebriety.

system in which the excessive use of drugs is a symptom,
follows a different line of degeneration from that called
hypnosis. In one case, general organic degeneration exists;
in the other, the power of control is broken up, and follows
suggestions from without. Of course no state of poisoning
from any of the drugs used in inebriety will permit the
power of hypnotic influence to dominate the acts or
conduct of the case. When the poisonous effects of the
drug have passed away, then the unstable nerve centres will
respond to external influences in various degrees.

If hypnotism is a physiologic state resembling sleep, and
not an abnormal condition — only a peculiar susceptibility
to certain external influences — it would seem that the
inebriate seldom would, if ever, be affected by it. The
observed facts vary widely, and are not sufficiently clear or
well-attested to form the basis of any authoritative conclu¬
sions. The few observers in this special field have not found
the same conditions even in the same cases ; and at different
times widely varying degrees of susceptibility have been
noticed. On the cessation of the drink paroxysms or when
from any cause the person abstains from drink, the reaction
is followed by a period of psychical weakness. In some
cases intense melancholy, or hyperesthetic sensitiveness,
and fears of their condition, are fertile fields for hypnotic
influence.

At this time, there is a degree of prostration and absence
of assertive will-power, with strong tendencies to depend on
any influences which will afford help. Good illustrations
are seen in temperance revivals, where at the command
of the enthusiastic orator they go forward and sign
pledges, make prayers, recite experiences, and assert positive
changes of life and character. These are hypnotic phe¬
nomena along coarser lines, and their potency is apparent in
the very small number of cases that are permanently bene¬
fited. In these cases the impression of a dominant idea has
become so fixed as to overcome all other tendencies to use
spirits again. Personal counsel, advice, threats, and appeals

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Hypnotism in the Management of Inebriety . 141

are followed by the same obliteration of the drink symptom
in an equally small number of cases.

The inference is that at this period in the progress of
inebriety, hypnotism skillfully applied may have a marked
value. Experience differs widely, and the power of a con¬
trolling influence one day is lost the next; and the idea that
seems so strongly held at one time disappears later. The
case which appears to be controlled by the operator sud¬
denly breaks away and the theories are disproven. There
seems to be a struggle between the morbid impulses of a
degenerating brain and organism, and the power of sugges¬
tive thought. The latter appears to be both physiologic and
pathologic : physiologic when the brain naturally turns for
guidance and direction to others, and readily accepts state¬
ments of facts which are presented in an emphatic way;
and pathologic when suffering from adverse conditions and
seeks relief in the promises and suggestion of others. The
power of hypnotism in the reactionary state of inebriety
is apparent in many ways, although not explained or under¬
stood, and the permanency of this control is still more
obscure. The same power in cases who are away from this
period, and are termed restored, used to prevent them from
taking spirits again, is equally obscure. In one instance this
power gave the inebriate a special repugnance to drink in
a certain old circle of friends, but did not stop him from
drinking alone. In another case, he claimed he could not
drink in his native city, but drank in a distant town. The
power of suggestion that one can not drink again, may hold
intact for an unknown period, but its permanency depends
on the degree of physical vigor and health, and other in¬
fluences. This is illustrated in the gold cure specifics.
The profound impression made on the organism by narcotic
drugs, is strengthened by the hypnotic force of a dominant
idea ; spirits can not be taken again. This in a certain
number of cases is real, as long as the person gives unusual
care to his physicial condition. If curiosity tempts him to
test this statement, the delusion is quickly exposed.

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142 Hypnotism in the Management of Inebriety .

It appears clear that hypnotism is a power in the treat¬
ment of inebriety, but its application is limited to cases not
under the influence of spirits or drugs. It is not clear that
these cases can be so positively controlled, or that command
or suggestion will last as long as in other cases. Evidently
clearer and more exact studies are necessary on this topic.

Profound hypnosis that is continued from time to time on
inebriates varies widely in its action. Some persons assert
that its influence is permanent, others say it depends on the
presence or proximity of the operator. It is natural to
expect that a knowledge of the presence of the operator, and
a repetition of the power of control would finally become
dominant, to the extent of superseding all other morbid
impulses, and in this a cure could be said to follow. It
would be a question, whether the susceptibility to hypnotic
influence, frequently repeated, is a pathologic condition
resembling that which follows the degeneration caused by
spirits.

In a case mentioned by Dr. Kerr, in the free intervals
from drink in a paroxysmal inebriate, hypnotism was sought
and enjoyed. The man was hypnotized often, and the idea
that he could not drink impressed on his mind. He was
used to show the power of hypnotism on many public occa¬
sions. This was kept up for a long time, until the operator
moved away, when the man relapsed. This illustrated the
fact observed in other circles, that the frequent hypnotic
action will take the place of spirits, and is a condition that
is akin to intoxication, and in some cases may be agreeable
to the person. I have frequently been conscious of a
personal hypnotic influence over certain cases of inebriety
which was effectual in restraining them from drink at the
time. In all institutions a certain small number of cases
never drink in and about the building, irrespective of all
conditions. Such cases come and go without restriction,
but when away from_ the institution and its influences,
relapse at once. It would appear that both managers and
the institutions exercise a hypnotic power which enables the

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Hypnotism in the Management of Inebriety. 143

person to keep from drink. The same principle explains
the power of faith and prayer asylums, where a dominant
idea is urged with great intensity and impulsiveness, ‘and for
the time being is made to absorb all other thoughts. In
this way the morbid drink impulse is overcome by a class of
different ideas, which for the time break up every other
thought. This condition has reactions, and the men who
are most emotional and absorbed by the suggestions of help
and salvation, unbend in private, displaying very opposite
traits. This is evidence that the power is hypnotic and
depends largely on the operator and the surroundings. It
will be accepted as a fact that inebriates are less susceptible
to hypnotic influence, and such influence is more transient
and uncertain in its duration. Yet this is a power of great
therapeutic value in an institution where it can be repeated
and made continuous, and where the surroundings are under
the control of the operator. To apply it practically it may
not be necessary to at once dominate the will of the patient
and overwhelm his personality, in abject submission to
another’s will, only in certain cases. But in all cases the
dominance and continuous pressure of suggestion are the
essentials. Suggestions that can be carried out and en¬
forced by conditions of surroundings.

By studying these influences on susceptible cases, and
forcing their recognition suddenly or slowly, a power of con¬
trol is built up of practical value. A certain number of
inebriates are most clearly held under restraint by the
hypnotic influence of certain persons closely associated with
them. The death or removal of these persons is followed by
a breaking out of the drink impulse.

The special question to be answered is this : Have we in
hypnotism a therapeutic power of sufficient general applica¬
tion, in the treatment of inebriety and drug narcotics, to
demand a technical knowledge of its application and use ?
It appears that we have. Irrespective of all theories of
either the pathologic and physiologic action of this force, its
power over the brain centers is assured and demonstrable.

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144 Hypnotism in the Management of Inebriety.

As an anesthetic, its application in many cases has attracted
great attention, but how far it can be used to control
unstable and psychical diseased brain centers is not well
understood. It would seem that from the evidence so far,
its power in the treatment of inebriety should be utilized in
all cases. The operator should first become familiar with
the technique and the general principles of its application,
and then put it to practical use and test, the same as any
other therapeutic agent.

So far, it would seem the best results may be expected in
an institution where the operator can command the sur¬
roundings and conditions of the patient. The complexity of
all cases of inebriety would most naturally increase the
difficulties in the treatment, especially in the application of
psychic remedies, and favorable results are not to be expected
in the same proportion or degree as that which follows other
means. The fact that a few cases are greatly benefited is
the strongest encouragement for its more extended use.

In a summary of what appears to be the sound con¬
clusions of the present knowledge of this agent in inebriety,
the following may be stated :

1. The inebriate is a neurotic, and not a good subject
when under the influence of spirits and drugs for hypnotism.

2. After the withdrawal of the drugs, a period of
marked instability seems most favorable for suggestions.
This will be transient unless followed up with persistence.

3. Experience points to the wide extended influence of
hypnotism in inebriety, although not known as such, in the
psychic forces of public meetings, and the power of domi¬
nant ideas impressed with emphasis on the mind.

4. Clinical experience furnishes many facts which seem
to prove that in certain cases its value is very marked, also
promising from more exact studies greater results.

5. Evidently, hypnotism is yet to be studied and tested
by the same methods applied to all therapeutic agents. So
far, its value in inebriety is established, to what extent and
how far it can be used are to be settled by future observers.

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Treatment of Habitual and Periodical Inebriates. 145

THE GENERAL TREATMENT OF HABITUAL
AND PERIODICAL ALCOHOLIC, MORPHINE,
AND COCAINE INEBRIATES.

By Heine Marks, M.D., St. Louis.,

Superintendent and Surgeon in Charge of the St. Louis City Hospital; Member
of the American Medical Association, etc., etc., etc .

In these latter days every reputable physician approaches
with something of dread the subject of the treatment of
those classes of patients known as morphiomaniacs and dip¬
somaniacs. So much has been spoken and printed on this
subject; sp much has been illegitimately claimed for so
many nostrums; it has become such a “ fad ” with so many
grasping and irresponsible members of the medical profes¬
sion — that the practitioner who attempts to discuss its va¬
rious features and phases and treatment must make up his
mind in advance to undergo malignant misrepresentation at
the hands of proprietors of the legions of specifics and so-
called “ cures.” If this were all, however, no one would be
in any wise deterred. But the conscientious investigator is
met at the outset with hostile criticism and the suspicion of
empiricism from indifferent members of his own profession.
Nevertheless, I feel that there are certain things which
should be said, certain facts which ought to be cited ; and,
in my capacity as superintendent of the St. Louis City Hos¬
pital I have had an experience somewhat out of the ordinary,
the results of which I gladly give in the hope that they
may prove interesting and valuable to the profession at
large, and helpful to victims of the morphine and kindred
habits.

Thus far I have taken note of thirty six hypodermic mor¬
phine and opium smoking patients whom I have treated. So
far as I have been able to learn, only two of these have since
Vol. XVIII.—23

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146 Treatment of Habitual and Periodical Inebriates .

lapsed; and as these were men who seemed to be beyond
the pale of influence of a moral consideration, and of whose
“ staying qualities ” I was at no time very sanguine, I am in¬
clined to feel somewhat pleased with my success. It must
be borne in mind that these patients were in no sense easy
ones to handle. Most of these men and women were chronic
“ hypo fiends,” and had been taking the drug subcutaneously
for periods ranging from one to fifteen years. The quan¬
tities injected varied from a minimum of 5 grains to a maxi¬
mum of 80 grains per day. The “ hop fiends,” or opium
pipe smokers, in some cases frequently smoked constantly
in every hour of the twenty-four, except the few hours during
the day in which they were overcome with sleep.

Of course, all habitual users of opium and its derivatives
are difficult to cure of the habit, and I need not tell the pro¬
fession that the very worst and most distressing- cases find
their way into such institutions as the St. Louis City Hos¬
pital. Not a few of these men and women were absolutely
poverty-stricken. For a long time previous to their coming
under my care some of them had been insufficiently clad and
nourished, having voluntarily deprived themselves of proper
clothing and food, and not infrequently gone without lodging
that they might procure their favorite intoxicant. As a con¬
sequence, I found their intense craving for morphine compli¬
cated with extremely low vitality, with derangements of the
nervous system, with cardiac and pulmonary affections, and
with various rectal troubles. These were certainly complex
and discouraging cases to treat, and the very fact of success,
despite these obstacles, is an impressive object-lesson, which
is a gratification to myself, and ought to be an incentive to
the profession generally.

At the outset, I wish to say that I do not claim my suc¬
cess to have been due to any new or startling discovery.
I simply took old and proved medicaments, and made such
combinations thereof as seemea most likely to produce a
given desired result. As a preliminary, I made sure that
the fundamental and essential ingredients were absolutely

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Treatment of Habitual and Periodical Inebriates . 147

pure. Then I compounded them personally. The principal
medicaments which I used were the old and well-known bit¬
ter tonics. I found an efficacious remedy in assayed Peru¬
vian bark (cinchona) select, which contains 3 per cent, of
quinine and 8 per cent, of alkaloids. I also found useful in
this respect Colombo, gentian, and other bitter tonics, with
aromatics. It is notorious that the market is flooded with
various worthless compounds of these and similar ingredi¬
ents, and that the proprietary or “ quack ” companies set
afloat an imperfect and unreliable product because they are
constantly seeking a preparation in /which there shall be a
very large margin of profit. They use inferior drugs, and
in striving to prepare tinctures they resort to any and
every means to save alcohol, on account of its being so
expensive.

The usual symptoms following the deprivation of mor¬
phia are that all of the secretions of the body are increased;
there is running at the nose and eyes ; diarrhoea and vomit¬
ing; acute gastritis; cramps or excruciating pains in the arms
and legs ; contractions of the muscles of the face ; restless¬
ness ; insomnia — in short, all the general conditions which
we get in nervous prostration. In general, I administer a
dose of one of these bitter tonics every two hours. Sedatives
and hypnotics are given according to the special needs and
condition of each patient. Nourishing and tempting food is
set before him as soon as it is craved, or can be taken with¬
out subsequent distress ; but there is no forcing. The usual
baths and sanitary measures are, of course, enjoined.

In cases of acute alcoholism, where a quick restoration to
a normal condition is necessary or desirable, I have devised
a plan which has never failed to prove efficacious. This is
simply washing out the stomach. The apparatus for this
purpose consists of a glass funnel inserted in the end of a
rubber tube leading into the stomach. Through this I pour
plentiful quantities of salt water, until vomiting ensues and
the stomach is thoroughly washed out. The patient is then
placed in a hot bath and afterwards immersed in cold water.

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148 Treatment of Habitual and Periodical Inebriates.

In fifteen minutes he is comparatively sober, and the next
morning perfectly so, and steady, too. By this device I
have been enabled to save for the city a great deal in the
way of salts, bromides, chloral, and other drugs. This treat¬
ment arrests gastritis, and, in experienced hands, never fails
of accomplishing the desired result, though in inexperienced
hands it might be attended with great danger.

In prolonged acute alcoholism it is sometimes necessary,
or at least merciful, to administer alcohol, but it should al¬
ways be given in a disguised form. This extension of mercy,
however, should not enter into the treatment of opium or
morphine patients. There should be no “tapering ” in such
cases, for the reason that the suffering consequent upon the
deprivation of the last quarter or eighth of a grain of mor¬
phine, after the “tapering” process, is just as great and just
as prolonged as though the administration of the drug had
ceased abruptly when treatment commenced.

It is not unusual to find hypodermic morphine users com¬
bining cocaine with their preparations, sometimes to the ex¬
tent of from 12 to 15 grains per day. The soothing qualities of
cocaine are well known to the profession. In most cases the
cocaine is added to deaden the pain caused by the frequent
use of the hypodermic needle.

There recently came under my observation and treat¬
ment a peculiar case — that of a young man who was a vie
tim of self-injected cocaine and strychnia. He admitted to
me that he had been taking this rare combination for about
a year, and had reached a point where his system required
30 grains of cocaine and 2 grains of strychnia per day. He
was found unconscious in the street by the police, and
brought to the hospital for treatment. To my surprise, he
voluntarily told me that he had been engaged in the founding
of “ institutes” for the cure of the liquor, opium, and morphine
habits in various parts of the country for two years. Had
it not been for the unwritten law concerning professional
secrecy, I might easily have obtained the formulae used from
him. I did learn, however, that in the treatment of morphine

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Treatment of Habitual and Periodical Inebriates . 149

cases he “ tapered ” them, at the same time keeping them
more or less under the influence of chloral and bromides.
He said that he used the same formulae as those employed
by a company of more than national notoriety, which he
claimed to have obtained in Europe from the man who sold
them to the head of the American company. In all, he (the
patient) claimed to have established about fifty “ institutes **
in this country, and had reaped great financial gain there¬
from.

The habit of opium smoking is almost .always contracted
through curiosity and association — hence, the moral influ¬
ence is often found to be of great assistance after repairs to
the physical system have been made. Contrary to the opin¬
ion so long and generally held, this habit is more easily
broken up than either the alcoholic or the morphine habit.
Those who take morphine through the stomach are, likewise,
much more easily and quickly cured than when a hypodermic
needle is used.

Permanent cures of those who inject morphia and those
who drink alcoholic liquors excessively are by no means so
plentiful as they are reported to be. The “ periodical/* is
the most difficult type to treat among the alcoholics. Their
attacks seem to recur at certain regular intervals, or in grad¬
ually diminishing cycles, preserving, as it were, a sort of
rhythm. They can be easily “ wound up/* and will run with¬
out aid of any kind for a certain period. When persistent
sleeplessness occurs, during seasons of abstinence, the mind
assists the body in overthrowing the enfeebled will. Even
in cases where a man yields but rarely, his life is, at these
times of restless craving, a hell upon earth. Any physician
who makes a study of the “periodical *’ alcoholic will be sur¬
prised at the extent to which heredity enters as a factor.
Take the case of the lamented Edwin Booth, for instance.
He inherited a strong appetite for alcoholic liquor, which
only at rare intervals overpowered him. He knew better
than anyone could tell him of this natural tendency, but
could not at all times conquer it. His admirers throughout

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ISO Treatment of Habitual and Periodical Inebriates .

the whole country were shocked when he pitched forward
near the footlights while he and Barrett were playing to¬
gether in New York. Later, to a sympathetic friend, he
said : “I never drink at a social gathering. My start is al¬
ways a solitary one. The very men who coax me to drink
at a banquet are the ones who would first avert their faces,
or spurn me with their feet, when they saw me lying in the
gutter, where I should eventually and inevitably land.”
What a sidelight is this on the perpetual struggle that tor¬
tured and embittered the life of this great actor — how it
adds the element of heroism to the character of the man
whom we were accustomed to regard solely as a histrionic
genius !

In strong emotional natures, when these periods of
temptation occur, there seems to be absolutely no preventive
save temporary restraint, isolation in the country, or a long
sea voyage, with accompanying medical attention. Will
power alone cannot avert the explosion. The patient’s con¬
dition seems to run its independent course, and must “ come
to a head ” as naturally and inevitably as does a boil. The
“ periodical ” drunkard is sufficiently desirous of leading a
life of sobriety to abstain entirely from the use of liquor for
a considerable time. As he grows older, however, these pe¬
riods of sobriety become shorter in length, through gradual
mental and physical enfeeblement, until the man who for¬
merly “ went on a spree ” once a year shortens the intervals
to four months, three months, two months, and finally
sinks into the condition of the habitual, well-nigh hopeless
drunkard.

One “ periodical, ” who came under my observation,
puzzled me for a long time. The man was intelligent and
apparently sincere in his desire to permanently reform ; yet
at the very first opportunity he would get stupidly drunk. I
despaired of ever effecting a cure in his case, until the
thought struck me that perhaps he was afflicted with a
nervous derangement distinct from the alcoholic appetite. In¬
quiry confirmed theory into fact—he had been troubled thus

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Treatment of Habitual and Periodical Inebriates . 151

from childhood. I treated him accordingly and effected a
cure; yet he realizes, as I do, that at certain intervals he
will have to undergo similar temptations as long as he lives.
In this instance, mental and moral as well as physical, forces
were at work. Attacked first by nervous indigestion, he
soon lost his appetite entirely. After forcing himself to eat,
he experienced great distress, and finally his stomach re¬
jected all food. A little later on, insomnia was sure to fol¬
low. Protracted loss of sleep produced mental and nervous
disturbances which interfered with the performance of his
work and caused great irritability. In such condition I have
seen him, and really considered him as being for the time
mentally irresponsible. Restraint and treatment would
alone “ bridge over” one of these periods. If these aids
were not accessible, he would surely reach a point at which
every moral consideration would be swept away, and in a
spirit of desperation—expressed by his : “ Don’t care ! Any¬
thing is preferable to this”!—he would gulp down half a
dozen big drinks of whisky in quick succession, and then
continue to drink until he became stupid and sank at last
into the long-craved sleep, which always proved to be the
precurser of an exceedingly debilitating debauch. “ I am
afraid to trust myself with drugs,” he said to me, “and I,
know that whisky will ‘ do the trick,* with some prospect of
my awakening again in this life.”

There are no doubt thousands of similar cases, and there
surely ought to be some refuge for these unfortunates when
their “ periods ” approach. This man told me that he once
applied at a private hospital for restraint, and was informed
that there was not a single private room vacant. “But
you’d take me if I were drunk”? he asked. “ Oh, yes,” was
the reply — and the next night he was admitted as a patient,
stupidly drunk. All men have not the moral strength which
sustained Edwin Booth, but there are many who possess
something of his temperament and are not able entirely to
escape the degradation which he so heroically avoided.

The “cycling” recurrence of the appetite is by no means

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152 Treatment of Habitual and Periodical Inebriates .

so marked among the consumers of opium and morphia, yet
I have no doubt that it does exist in some degree. This be¬
lief is strengthened by the fact that in many towns and cities
in the West there are to be found certain peripatetic pander-
ers to “ hypo fiends.” These peddlers go well provided with
the drug and a syringe, somewhat after the style of the
“ walking liquor-stores ” peculiar to Kansas, and have their
regular customers among gamblers and prostitutes, whom
they call on and “ shoot ” at certain hours every night. If
the “hawker” be even a minute late his customers become
restless, and after a five-minutes wait they are almost fren¬
zied. Promptness and reliability are, therefore, the chief
and only merits of these morphine-peddlers. Among the
classes referred to, alcohol is too much of an excitant, and to
carry on their several occupations with ease it becomes
necessary that they should have frequent and regular injec¬
tions of morphia.

Just here I wish, parenthetically, to call attention to a
lamentable fact, and one far from being creditable to the
medical profession. So far as my observation and inquiries
have extended, I have found that less than 25 per cent, of
morphine users have become slaves to the habit through
curiosity and association. By what means, then, have the
other 75 per cent, acquired the appetite ? I am compelled
to the conclusion that it was through the recklessness of
ignorant and unskillful physicians. Of course, there never
was a morphine user without a plausible excuse for the form¬
ation and continuation of the practice; but I feel that this
estimate of 75 per cent, is under, rather than over, the true
number chargeable to physicians, and is as nearly correct as
it is possible for an estimate to be. These unintelligent
physicians are not close enough observers to determine the
existing cause which produces a certain pain, and, not know¬
ing what else to .do, they prescribe morphia. They are thus,
at least, reasonably sure of giving the patient temporary re¬
lief. Physicians of this calibre ought to be classified with
criminals. Our modern educational system is in some de-

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Treatment of Habitual and Periodical Inebriates. 153

gree responsible for their existence. A large number of
physicians now being graduated from medical colleges are
men who are wofully lacking in fundamental education. A
host of these incompetents is turned loose every year, and
their ranks are being constantly augmented. There are too
many medical colleges in this country. These must neces¬
sarily have students to sustain them. Therefore they enroll
nearly every applicant for admission. Not a few institutions
offer tempting inducements in the form of lenient examina¬
tions and cheap fees, thus encouraging young men of no
education or fitness whatever to embrace the profession, and
leave the plow — to inject morphine. These are the men
who are mainly responsible for the vast increase in the army
of unfortunates whom I have been describing. They flour¬
ish principally in the new communities of the Far West.
The reason for this is not hard to find. In the large, con¬
gested cities of the East, and even in the smaller towns and
villages, it is tedious and difficult for a young man to estab¬
lish a practice, except in association with and under the
guidance of an old and experienced member of the profes¬
sion. Hence, the newly-fledged practitioners too often “ go
West to grow up with the country.” The records of the va¬
rious sanitariums establish the fact that the number of vic¬
tims who have contracted the pernicious morphine habit in
Kansas, Nebraska, New Mexico, Arizona, Utah, Wyoming,
Idaho, Montana, and the Dakotas is out of all proportion to
their several populations, as compared with those of eastern
states. Dissipation, anxiety, excitement, exposure, privation,
and hardship render residents especially liable to fall into
the hands of these young practitioners — after which, God
help them !

In this respect, there is one educational reform which I
should like to suggest. Professors in our medical colleges
teach too much physiology, pathology, and anatomy — or,
rather, too little materia medica, or the application of medi¬
cine to disease. Thus unevenly equipped at the outset, these
young doctors prescribe morphia to relieve ordinary transitory
Vol. XVIII.—24

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154 Treatment of Habitual and Periodical Inebriates .

pains, and the relief following the practice induces them to
persist in it until their clientage of this character assumes
alarming proportions. Too often they tell their patients
what they are giving to relieve them. I am not one who
believes that a physician should thus take his patients into
his confidence. There are entirely too many of that sort of
pseudo-partnerships.

I have no faith whatever in the so-called “ home treat¬
ment ” theory. Nor do I think it possible to reform a real
“ fiend ” in that manner, be his special intoxicant what it
may. Even in sanitariums the patients must be, for a con¬
siderable time at least, under the special care and watchful¬
ness of the physician in charge. Visitors must be rigidly
excluded, for they, in mistaken kindness, are apt to smuggle
in liquor, or morphine, or opium. Mail matter should be
opened in the presence of the physician, for opium and mor¬
phine have been known to travel in that way, and otherwise
honorable men will lie and deceive where their special long¬
ings are concerned.

The complications of each case must be studied separ¬
ately, and the idiosyncracies of each individual noted, and
when possible, humored. Gregarious patients should be al¬
lowed to congregate if they choose, but others thrive best in
solitude. With no other class is it so essential that the
physician should possess the confidence of his patients. Each
should feel that a special study is being made of his case,
and that special treatment is being given him. Every
“ fiend,” of whatsoever description, has a conviction that his
own particular case is peculiar and remarkable, and that his
sufferings surpass in intensity those of all other persons sim¬
ilarly afflicted. After a few days of treatment, the patient
commences to experience relief, heightened by contrast with
his recent pain; he takes food with relish, and from this
time forward usually gains flesh rapidly.

I do not believe that any remedy has ever been or ever will
be devised that will infallibly cure every case. There are any
number of so-called “ cures,” or “ substitutes,” which will

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Treatment of Habitual and Periodical Inebriates . 155

alleviate or remove present suffering, and temporarily re¬
strain a “fiend” from indulgence; but the percentage of
permanent cures is small and variable, and there is no means
of accurately determining what proportion of cases treated
remains cured. The difficult factor to differentiate — the
unknown quantity — is the number of persons who are cured
through the influence of the mind, or by what has come to be
known to the profession as “ suggestion.” A man who has
remained “ cured ” for six months or a year, and to whom the
vendor of the remedy “ points with pride ” as convincing
evidence of its efficacy, may, through a combination of cir¬
cumstances, “break out” again at any moment. There is
certainly nothing in the medicines given that will prevent a
man from drinking liquor, injecting morphia, or smoking or
eating opium — if he wants to. In most instances, those who
have undergone treatment are told that if they relapse they
“ shall surely die.” In some cases this has proved true — in
others it has not. It goes to show, however, that the drugs
administered were harmful, or dangerous, and probably pro¬
duced organic changes which impaired the constitution of
the patient. It also illustrates how strong the appetite is in
some men, when they will voluntarily resume such a habit in
the face of so impressive a warning. If it is simply a question
of fighting one poison with another—why, anyone can do
that; but when such a combat is arranged by ignorant and
unscientific men, who are solely “out for the stuff,” the
evil becomes an appalling one and demands vigorous re¬
pression.

One palpable mistake of the vendors of secret or patented
nostrums is in treating all cases alike. There is no universal
panacea. There are many reasons why the treatment of
these three classes of patients, and even of the different
types of the same class, should not be identical, as it is at so
many sanitariums. How any sane physician can range
scores, or hundreds, of morphine, opium, and alcoholic users
in line, give each the same (or approximately the same) med¬
ications hypodermically, and identical internal medicine —

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156 Treatment of Habitual and Periodical Inebriates.

and yet hope for success, passes comprehension. The only
explanation that occurs to me is that the sway of the mind
over the body is much greater than we give it credit for.
The more cases I observe the more am I impressed with the
psychological influence. The “ impressionable ” or “ sympa¬
thetic ” natures of some men render them peculiarly liable to
contract and be divorced from physical and mental disturb¬
ances. In proof of this assertion, I might cite an instance
where an eminent neurologist, the head of one New York’s
great insane asylums, became mentally disturbed through
contact and association with the unfortunates under his care.
Happily, he was in a short time restored to complete control
of his mental faculties. In my own experience I have found
a “ placebo ” to work admirably. Morphine sufferers have
implored me to give them relief, and a little distilled water
has produced the desired effect. Where a single injection
failed, a second, or a third, was sure to bring ease and qui¬
etude. It is truly a remarkable exhibition of the power of
imagination.

At all large sanitariums the apparent success of the rem¬
edy is thus emphasized. Men “ imagine ” that they have in¬
herited or acquired an appetite, or a tendency toward an ap¬
petite, for opium, morphine, or liquor. Being easily im¬
pressed, they are just as quick to “imagine" that they are
“cured,” especially when they hear of and see so many
quondam slaves uniting in a paean of exultation over their
new sense of freedom. Alas, that it should so often prove
to have been but a Barmecidal feast! Probably the “ cures ”
least likely to be permanent are those of what are known as
“village drunkards.” Every hamlet has at least one of these.
The ambition to be regarded as an unfortunate, incorrigible
drunkard has been nursed and indulged so long that it has be¬
come a sort of “ second nature” with them, and at times amounts
to an acute eccentricity. When the public sensation excited
by their reformation has become stale, they “ feel lost ” with¬
out their accustomed notoriety, and speedily “fall.” And
when they do “fall ” they “fall hard,” else their craving for

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Treatment of Habitual and Periodical Inebriates . 157

public notice would not be completely gratified. These are
the men who can be found lounging in sanitarium hallways,
or on curbstones, loudly proclaiming, after three or four
days’ treatment, that they are completely cured and could
not take a drink of whisky if they tried.

Other important factors to be considered are age, con¬
stitution, present physical vigor, previous habits, tempera¬
ment, and occupation. A considerable number of these
patients will be found to be night-workers, legitimate or other¬
wise. Sleep can, of course, be induced in such more quickly
and easily during the daylight hours in which they have been
accustomed to rest. I have had patients who were heavy
and “ droopy ” all day, but who aroused immediately when
lights were turned on in the evening, and whose mental
activity was greatest between 10 o’clock and an early hour
in the morning. In this last-named interval no ordinary
hypnotic seemed sufficient to make them drowsy. Their
systems would “ shed ” heavy doses of the bromides, chloral,
sulfonal, hyoscyamus, and paraldahyd like water from a
duck’s back.

One other important aid, available alike to pretenders
and legitimate practitioners, is mental rest. By this I do
not mean absolute indolence, but a temporary divorce from
“business.” In some cases this is obtained by a sojourn
in the mountains or at the seashore, or a sea voyage or pro¬
longed yachting excursion. I know one of the great finan¬
ciers of the country, and also an eminent lawyer, who have
been nominally “ cured ” at one of the many sanitariums —
the former of the morphine and the latter of the “ periodical ”
alcoholic habit. They have told me that, after having once
received treatment they dropped all “ business ” and returned
to the sanitarium when they began to experience a feeling
of exhaustion, coupled with a longing for their favorite stim¬
ulant. At first they returned four times a year, then three
times, and now manage to get along with two visits per annum.
They tell me that they do not know how much merit to ascribe
to the medicine, but that the change of scene and repose of

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158 Treatment of Habitual and Periodical Inebriates .

the particularly overtaxed faculties certainly aid largely in re¬
storing them to such a state of mental health that they can
grapple easily and with self-confidence with hazardous money
transactions and legal cases involving many thousands of
dollars. This brain rest and repair they cannot obtain at
the “ Springs,” or the fashionable resorts, and to “make
sure ” of restoration within a month, they give the medicine
the benefit of the doubt, instead of going off on a hunting,
fishing, or yachting trip. The truth is, these gentlemen are
far-advanced victims of nervous exhaustion, and are doubt¬
less benefited by the course of tonics and the general sur¬
roundings, which tend to inspire mental repose and confi¬
dence in the ultimate result. Before permitting themselves,
as hitherto, to become entirely “ worn out,” they simply
“take a rest” and thus avert re-enslavement to their favor¬
ite stimulants.

The abnormal craving for liquors or drugs is usually
found to be complicated with some organic derangement.
Catarrh, bronchitis, and liver and kidney diseases are the
most frequent accompaniments. When there is pronounced
or chronic disturbance of the brain or nerves, reform is
scarcely to be hoped for; with other disorders, the case does
not present such great difficulties. Oftentimes a pernicious
habit may be broken off by removing the local derangement
which precedes or accompanies it. In women the co-existent
disturbances are usually of the uterine or spinal nerves.

One of the symptoms most distressing to the morphine
or opium patient is the loss of vitality occasioned by frequent
orgasms and copious seminal emissions. When first de¬
prived of the drug, male and female alike are not free from
these terrific drains on their vitality, sleeping or waking.
In some cases they occur every five or ten minutes. It is
is not unusual for a patient to have ten or twelve of
these emissions through the night and eight or ten
during the day. In those not addicted to excessive
sexuality, the emissions rarely exceed two per day.
These seminal losses are not an invariable accompaniment,

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Treatment of Habitual and Periodical Inebriates. 159

but they may fairly be classed as general. It is necessary
to check the emissions as soon as possible, for no relief can
be obtained while they continue with such frequency and
quantity. Consequently, I administer the most nourishing
food—frequently a dozen or more eggs per day, with milk
ad libitum.

Another popular fallacy is the taking it for granted that
all over-indulgence in harmful drugs is due solely to a physi¬
cal cause. In my experience I have found three factors,
any one or all of which may be powerful in a given case.
These are the mental, the moral, and the physical. The
fact which I wish to make emphatic is that any method of
treatment which fails to take cognizance of mental and
moral causes and influences will surely prove a failure. In
other words, the source of most of these abnormal con¬
ditions, appetites, and indulgences is to be sought within
not without.

As to the immoral phase of morphine-taking we know
but little in this part of the country. The Western states
and territories are the places where it can best be studied
face to face, and knowledge of it can only be obtained here
through conversations with “ fiends ” from that section of
the country. The immorality of the practice will be con¬
ceded when we reflect that most of its devotees there are
gamblers and prostitutes. For this reason it is extremely
difficult to work a permanent cure in one of them unless
an absolute moral reformation be accomplished. Hence, I
always urge upon my departing patients the importance of
breaking off all old associations that are vicious, and of a
complete change of environment when possible. I do this
because I am convinced that no medicine can entirely renew
wasted, weak, and flabby nerve-cells. All that we can do is
to assist nature in partially restoring them, and to so change
the occupation, diet, social condition, and surroundings that
a sufficient reaction may be produced in the nerve-cells of
the person treated to enable abstention to be easily per¬
manent.

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160 Treatment of Habitual and Periodical Inebriates.

Continued physical or mental excesses are sure to create
a tendency : First, toward the use of a stimulant t q flagging
mental and moral and physical energies; and, next, toward
the employment of a powerful sedative. Hence, the drink¬
ing of alcohol is quite naturally superseded by the smoking
of opium. This is, at first, found to be deliciously satisfy¬
ing, and the moral sense is blunted by the reposeful social
features incident thereto. The newly-developed smoker at
once becomes an active instrument for the propagation of
the practice. He begins by inducing his intimate associ¬
ates, male and female, to “try a pipe.” The insidious and
powerful nature of the drug renders it both an alleviator of
mental anxiety and physical pain and weariness, and a terri¬
bly fascinating and soothing sedative. But, after a time, the
victim’s system becomes so thoroughly impregnated with
opium that he can scarcely smoke enough to satisfy him. In
an evil hour he takes a few injections of morphia. Thus he
“ graduates ” from a “ hop fiend ” into a “ hypo.” The effect
of morphine is much more powerful than that of opium,
being, when taken subcutaneously, about six times as strong

— and “action is had” more quickly by means of it. There
is a saving of time, too, and, instead of sinking into a state
of stupor for hours, the partaker is nerved to greater achieve¬
ments without any increase of effort or weariness. In the
East, except in a few large cities, the morphine habit is a
secret one; in the West, it is an eminently social custom.
Groups, or circles, or coteries of congenial men and women
get together and “shoot” one another through the hypo¬
dermic needle. These people do not regard the morphine
habit as an immoral one. At first some of them may have
done so, but frequent repetitions soon blunt all moral sus¬
ceptibility.

Nor is this moral paralysis peculiar to uneducated people

— it afflicts the cultured and refined, in the end, also. The
standard of right and wrong, after all, is a matter of individ¬
ual judgment, when not fixed by law.

Most morphine users are without hope of permanent

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Treatment of Habitual and Periodical Inebriates. 161

reformation, while opium smokers and alcoholic drinkers are
always sanguine of attaining to a state of freedom. All mur¬
derers cherish hopes of being spared from execution on the
gallons, but the enthralled “ hypo ” fully realizes that he
cannot escape tortures worse than death, even should he be
eventually rescued from the grip of the habit.

A knowledge of the psychological laws governing what
we call “ Suggestion ” is what the medical profession stands
in need of. Causative forces are not understood. Scientific
men have endeavored to deduce laws governing abnormal
conditions of the mind, and have failed. The only thing they
have demonstrated is their own ignorance. Many natural
la^ys doubtless exist which are totally unknown to us, by
virtue of which the nervous system may become susceptible
to impressions not ordinarily received. That the mind has
a distinct nature and a distinct reality apart from the body,
and yet frequently controlling it, or acting in co-ordination
with it, will probably be conceded by most students of men¬
tal science. Certain conditions may be absent in some per¬
sons, and marked in a few, while between these extremes
there may be every gradation, from the faintest impression
to the most vivid reality.

Now, these lamentable cases which I have been consid¬
ering do not “happen ” —they “grow ” —and they are just
as surely the result of evolution from “ within ” as animal
life is. The “ within ” is hidden from us ; we know noth¬
ing of so-called “ Soul Life ; ” but we have progressed suffi¬
ciently far to be able to assert that every full-fledged action
is a lawful sequence of previous incubation, nourishment, and
growth. It is also demonstrable that what men dwell upon
they become like, which is one way of illustrating the power
of mind over matter. There are doubtless special forces
which germinate the indulgences under consideration. How¬
ever spontaneous or impulsive any given offense may appear,
the foundation upon which it rears itself has been of slow
and gradual growth from miscellaneous, sedimentary im¬
moral deposits. A vent would have been found somewhere.

Vol. XVIII.—25

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162 Treatment of Habitual and Periodical Inebriates .

The tendency of the age is in the direction of abnormity
— mental, moral, and physical — or, rather, in the contem¬
plation of abnormal phenomena, and the deducing of gen¬
eral laws therefrom. This brings us into that most delight¬
ful domain — psychology. This branch of mental science is
entrancing almost to the verge of painfulness. But we find
there have been many explorers in this realm before us. The
whole world is full of “ Suggestion,” and hypnotism is only
an infinitesimal part thereof. It would be easier for the
progressive medical man to write a book than a paper on
“ Suggestion,” as applied to the practice of medicine, espe¬
cially in the cure of mental and nervous diseases.

We are certainly on the eve of great discoveries in men¬
tal science. Only a few years ago many operations in head
and abdominal surgery, which are now performed daily with
success, were unthought of, the cases pronounced “ hope¬
less,” and the patients abandoned to die as comfortably as
possible. Who knows but that the incipient paretic may
yet be restored to a life of reason by the aid of surgery, in¬
stead of being confined to await the awful “ explosion ”
which precedes death ! A true understanding of mental
science is all that is needed in the various cases which I
have been considering. As soon as we comprehend the
laws of any force or thing, we have it not only under con¬
trol, but harnessed for use.

The theory of “ Suggestion ” is a proper subject for in¬
vestigation at the hands of the medical profession. Many
patients are habitually in the subjective condition; others
desiring to be cured can easily bring about such a receptive
state of mind. This important branch of legitimate prac¬
tice must be wrested from the hands of quacks and charla¬
tans. They are not so blameable, after all, for claiming to
destroy the alcoholic, opium, and morphine appetites, when
they know that they can rely upon that mighty and myste¬
rious agent, “ Suggestion,” to aid them. True, they employ
it ignorantly; but who is there to challenge and expose
them, when reputable practitioners are too indifferent to in-

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Treatment of Habitual and Periodical Inebriates . 163

vestigate for themselves ? These crude and ignorant pre¬
tenders claim to know all about the laws that govern mental
phenomena, but educated and experienced investigators
know that neither themselves nor the quacks understand
anything about them.

“ Suggestion ” is too powerful an ally of medical science
to be ignored, or permitted to be employed solely by ignor¬
ant and unprincipled men, whether inside or outside of the
profession. I appeal especially to the neurologists — that
sturdy and growing wing of our profession — to give the
subject more careful attention. In the single department
which I have been discussing there is a splendid field for an
earnest, sincere investigator, aided by pure drugs and “ Sug¬
gestion." This fertile ground has been almost entirely
abandoned by quacks, with their worthless nostrums, while
thousands of victims of alcohol, opium, and morphine are
crying unto you, legitimate members of the medical profes¬
sion, to save them.

I am constantly in receipt of letters asking me if I think
I can “ cure ” a husband or a son. In a touching letter re¬
ceived a few days since from the far West, I am besought
to treat the husband of th£ writer. “ The doctor adminis¬
tered morphine when my husband had the rheumatism,”
writes the wife, “ and it seems as though he couldn’t possi¬
bly give it up. He is a good man, and knows that I am
writing to you. Can you not treat him at home ? If not,
although we are poor, I will go to St. Louis and keep him
company until you say he is cured. Somehow, we both have

faith in you, but we have none in the-Cure, for we

have seen too many honest men fall back, into their old ways
after having taken that treatment." This is a sample of
many other similar appeals which I am compelled by cir¬
cumstances to deny.

The “ bunco" physicians are waxing fat and impudent
off the woes and credulity of their fellow-beings. Some of
them are no better than the Hungarians who wrenched and
cut rings from the fingers and ears of dead women just after

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164 Treatment of Habitual and Periodical Inebriates .

the terrible Johnstown flood. They are harpies, pure and
simple. . Plain language should be used when referring to
them, and vigorous action should be taken against them.
They cannot follow us in surgery — do not let them precede
us in mental therapeutics. I hope to live to see the day
when paresis will be regarded and treated as a curable dis¬
ease, and when the worst morphine slave in the land may be
bidden to “take heart."

Do we not, as a profession, owe a great duty to the users
of morphine ? Have not more or less incompetent medical
men, ignorantly perhaps, inoculated thousands of them with
the woe-compelling and soul-destroying virus ? Is their any
other profession on earth whose members are so numerously
represented in the hosts of victims of morphia as our own ?

I have, however, given this subject my personal attention
for a considerable length of time; and I feel it to be my
duty to lay the results of my investigations before my pro¬
fessional brethren, and appeal to them to intelligently ex¬
plore and specialize this branch of medical science, and,
while “ rescuing the perishing," at the same time analyze
and develop that new and powerful ally — “Suggestion."

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Ophthalmoscopic Appearance of the Fundus Oculi , etc. 165

THE OPHTHALMOSCOPIC APPEARANCE OF
THE FUNDUS OCULI IN DELIRIUM
TREMENS.

By A. Edward Davis, A.M., M.D.,

Instructor in Diseases of the Eye, New York Post-Graduate Medical School
and Hospital; Assistant Surgeon , Manhattan Eye and Ear Hospital etc .

In the summer of 1894 Dr. C. L. Dana suggested to me
that I should study the condition of the fundus of the eye
in alcoholic patients while they were in the state of delirium
tremens. At the same time he afforded me entrance to the
alcoholic wards at Bellevue Hospital, where I could make
these investigations.

The fact that no such investigations have ever been
made heretofore in these cases may be accounted for by the
simple reason of the difficulty of making such observa¬
tions. A man in the state of delirium is not an ideal sub¬
ject for ophthalmoscopic examination, by any means, and I
may say here that my observations have not been altogether
satisfactory.

Altogether I examined but sixteen cases, eight of which
were in delirium tremens, and eight were acute drunks.
While the object of this paper is primarily to give the con¬
dition of the fundus of the eye in delirium tremens, yet I
incidentally add those of the acute drunks as a matter of
interest in this connection, especially as I find but few ob¬
servations in literature on such cases.

Case I. — J. McD., aged fifty-four years, laborer. Has
been in the hospital once before with delirium tremens for
a period of four days. For the last three months he has
been drinking steadily, whisky and beer being the two
beverages mostly consumed. Has not been able to eat for
the last two days. His general condition is fairly good, but

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i66

Ophthalmoscopic Appearance of the

now he has gastritis. Was admitted to the hospital to-day,
June 15th. No medicines yet.

Condition of the fundus oculi: The arteries and veins
are very large, and the veins tortuous ; and the blood in
both darker than usual. There is pulsation of the veins on
the discs, which appear white from contrast with the rest of
the fundus. No lesion in either eye. The pupils are
small, and react but slightly to light. A second examina¬
tion the following day, with the eye under the influence of
atropine, and after the patient had been given bromides and
chloral, showed the vessels somewhat smaller, and no pulsa¬
tion in the veins.

Case II. A. J., aged thirty-one years, chemist. His
first time to have delirium tremens, and he has them now
only in a mild form. He drinks everything in the liquor
line. General condition is good, but he has not been able
to eat anything for a day and a half. Has been drinking
for five years. Admitted to the hospital to-day, June. 23d.
No medicines.

Condition of the fundus oculi: The arteries and veins
both are much larger than normal, and filled with dark
blood. Passive congestion is marked. The discs appear
white from contrast. No lesion of either fundus. A
second examination under atropine the following da^ showed
but little change in the condition of fundus, though he had
been given bromides, chloral, etc. Was still in delirium.

Case III.—C. H., aged thirty-eight years, millwright.
First time to have delirium tremens. He was admitted to
the hospital three days ago, June 19th. Has mild delirium
during the day, and marked delirium at night. Has had
large doses of bromides and chloral since in the hospital.
Beer has been his chief drink, and he has been a moderate
drinker for years.

Condition of the fundus oculi: The arteries and veins
are moderately large, with venous pulsation on the disc well
marked in the right eye. Evidences of passive congestion.
No lesion in either eye.

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Fundus Oculi in Delirium Tremens . 167

Case IV. — C. R., aged thirty-three, barkeeper. Has
been in the hospital for two days, and has had large doses
of bromides and chloral, but still has marked delirium.

Condition of the fundus oculi: The arteries and veins
are but slightly enlarged, but the fundus in each eye is to
some extent actively congested. Slight pulsation of the
veins on the discs in each eye. A second examination
under atropine the following day showed no change in either
eye.

Case V. — A. G., aged twenty-five years, bartender.
Drank hard and steadily for two or three months before he
came to the hospital. For a week before entrance he would
retain but little or no food on stomach. He developed de¬
lirium two days after admittance, although he had been
given bromides and chloral.

Condition of the fundus oculi: The arteries and veins
are both very large and tortuous, with evidences of passive
congestion marked. The disc appear white from contrast
with the rest of the fundus. No lesion in either eye, though
he has a large amount of albumin in his urine, and is known
to have a parendhymatous nephritis.

Case VI.—J. M., aged sixty-two years, laborer.
Claimed by his friends that he has been drunk most of the
time for the last forty years. He drinks whisky and rum,
and has had delirium tremens twice before. His general
health is not good. Drinking heavily for the last two weeks,
and stopped yesterday simply because his stomach would
tolerate neither food nor drink. His delirium lasts for a few
hours, stops, then comes on again. Has had one dose of
bromides and chloral.

Condition of the fundus oculi: The arteries and veins
are both very large, the veins tortuous, filled with dark
blood, and with distinct pulsations on the discs. Pas¬
sive congestion quite marked. The discs appeared whiter
than normal, simply from contrast with the rest of the
fundus, as in the other cases. A second examination under

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168 Ophthalmoscopic Appearance of the

atropine the following day showed less pulsation of the
veins, but the passive congestion was still well marked.

Case VII. — M. G., aged sixty-four years, printer. Has
been drunk for the last five months on whisky and rum.
He is fairly well nourished. Has not eaten anything for the
last two days. Has had no medicine yet.

Condition of the fundus oculi: Widely dilated veins and
arteries, with pulsation of veins on the discs. The discs
are white from contrast. A second and a third examination
showed but little change in the fundus of either eye, though
the patient’s delirium was about gone.

Case VIII.—J. L., aged twenty-six years, housewife.
Has been drinking for the last two years. Went on a pro¬
tracted spree last week. Rum and whisky were the
chief beverages used. Delirium is well marked at night,
but mild during the day. Has had bromides and chloral.

Condition of fundus oculi: Large, dark veins and ar¬
teries, and discs white from contrast.

Besides the above cases, I examined the fundus oculi in
eight patients in the stage of acute drunk , two of which
were in acute delirium.

Three of these last eight cases had not been drinkers of
long standing. The fundus of the eye in these cases was
greatly congested, passively so, from the depressant action
that the alcohol had on the vaso-motor system. The ar¬
teries and veins both were dilated and filled with blood
darker than is ordinarily seen in congestions of the fundus.
The pupils were contracted in two of the cases, and normal
in the other.

Two cases were acute drunks of chronic drinkers. The
fundus oculi in these two cases were much like the eight
suffering with delirium tremens — that is, the arteries and
veins were large and tortuous and filled with dark blood
(passive congestion), and the discs appeared more or less
white by contrast with the rest of the fundus. In one of
these cases both arterial and venous pulsation were present,

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Fundus Oculi in Delirium Tremens . 169

although the tension of the eye was normal. The pupils in
each case were contracted.

Of the two cases with acute delirium, the fundus in one
was greatly congested, passively so. In the other, which
ended in stupor and death, the veins and arteries were very
large and tortuous, with pupils widely dilated and no reac¬
tion to light. This patient had been in acute delirium for
four days before he was brought to the hospital. He had to
be restrained for the first twelve hours in the hospital, when
stupor set in and ended life in the next twelve hours. This
patient was a very large and muscular man, weighing at
least two hundred and twenty-five pounds.

An eighth case of acute drunk was a dipsomaniac. The
fundus of the eye in his case was much congested. The
veins and arteries were dilated and darker than usual. The
patient went on sprees about every three months ; this last
spree had lasted for ten days.

The conditions of the fundus of the eye as observed in
the above cases of delirium tremens are not to be accounted
for wholly by the delirium. In the study of these cases the
physiological and pathological action of alcohol on the whole
system must be taken into consideration. The delirium
itself, in fact, is only a psychical phase of chronic alcohol¬
ism, due to nutritive changes in the nervous system, and
brought about, not by the primary action of alcohol, but by
its temporary withdrawal from the individual addicted to its
abuse. As a condition in itself it is but little understood.

“ The anatomical lesions after death from delirium tremens *
shed no light on the pathogenesis of the condition.

“ Meningeal congestion, oedema or piameter and of the
cortical substance of the brain, scattered minute extravasa¬
tions 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.”

The dilated, tortuous, and in some cases, pulsating ves¬
sels observed in the above cases, are not to be accounted for
Vol. XVIII.—26

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170 Ophthalmoscopic Appearance of the

altogether, therefore, by the psychical derangement of delir¬
ium tremens, but are due in part to the toxic action of alco¬
hol on the vaso-motor system of nerves. As is well known,
alcohol in physiological doses stimulates circulation, and in
toxic doses depresses it. On the vaso-motor system, to
which I wish to call special attention here, it acts as a de¬
pressant from the first; and this even in small doses, as
shown by the flushed face, which is due to dilated capilla¬
ries. And if the use of alcohol is persisted in the capillaries
become permanently dilated. In fact, this is one of the
earliest pathological changes produced by alcohol. A second
and graver one is the tendency to atheroma, while a third
and later one is sclerosis.

The dilated vessels in the fundus of the eye, in delirium
tremens cases, is due in great measure, then, to the depres¬
sant action of alcohol on the vaso-motor system, the toxic
action of the alcohol lasting for some time even after the
drug is withdrawn. The dilated vessels in the acute drunk
cases are certainly due to the toxic effect of the alcohol on
the vaso-motor nerves, which allows the vessels to dilate.

The very dark blood observed in the arteries and veins
in these ca^es is due to the lessening of oxidation in the
blood from the alcohol in the system — a well known phys¬
iological action of alcohol; partly, also to passive congestion.

The vessels in the fundus of the eye are subject to the
same changes from the action of alcohol and other toxicants,
as on the vessels in other portions of the body, although
Schulten, cited by Noyes, seems to think : “Toa remarka¬
ble degree the intraocular circulation is independent of the
systemic vessels because shut within a special cavity, yet a
slight relation exists.” In this view I think Schulten mis¬
taken, as is shown by the changes occurring in the ocular
vessels in the above cases, both in the delirium tremens and
in the acute drunks. Again : “ In cases of congenital mal¬
formation of the heart with cyanosis, such as defective
closure of the foramen ovule or stenosis of the pulmonary
artery, the retinal vessels show markedly the general disten-

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bundus Oculi in Delirium Tremens.

171

sion of the veins and the change of color of the blood. Lie-
breich gives a striking picture of such a case, and Leber
remarks that in two cases observed by him the dilatation
affects the arteries as well as the veins. ,,

Again, in Graves’ disease : “ Some dilatation and even
pulsation of the retinal arteries is found in some cases.”

Furthermore, we know that the vessels in the fundus of
the eye are among the first, if not the very first, to suffer
from the secondary changes in the numerous forms of
Bright’s diseases with albumen in the urine. Neither pri¬
marily nor secondarily, then, are the vessels of the fundus
exempt from the changes of the general circulation, but, on
the other hand, in some diseases they are particularly liable
to early change.

Where delirium tremens occurs in old alcoholics who
have toxic amblyopia, that is, degenerative atrophy of the
optic nerves, the vessels may be found normal in size, or, if
the degenerative atrophy is far advanced, even smaller than
normal. No such cases were observed by me in the above
eight. This lessening in size of the blood vessels is due to
the atrophy of the nerve and sclerosis of the vessels, and
not to the delirium in such cases. Toxic amblyopia, how¬
ever, and other ocular lesions such as neuro-paralytic kera¬
titis, paralysis of the ciliary muscle, night blindness, paral¬
ysis of the ocular muscles, xerosis of the conjunctiva, etc.,
etc., all of which may be caused by the abuse of alcohol, and
be coincident with delirium tremens, are not to be consid¬
ered in this short paper. Besides, they are fully elucidated
elsewhere.

The pulsating veins and in one case pulsating arteries, in
the above cases are to be accounted for in two ways : First,
by the slight increase of tension produced by the dilated
vessels, allowing more blood in the eye than it is ordinarily
accustomed to. It is a well-known fact, and one easily ver¬
ified, that by pressing on the eyeball with the finger, thereby
increasing the tension of the eye, while looking into the eye
with the opthalmoscope, a distinct pulsation can be observed

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172

Ophthalmoscopic Appearance of the

in the veins; and if the pressure is hard enough arterial pul¬
sation is produced. This same phenomenon — pulsating
veins and arteries—is sometimes observed in glaucoma,
where tension of the eye is greatly increased. Second, pul¬
sation in the veins, and even in the arteries of the fundus of
the eye, may be caused by an enfeebled heart, or by dilata¬
tion of the blood vessels with a resultant decrease of arterial
tension. Now, in delirium tremens all of the above condi¬
tions — conditions favoring pulsation of the vessels — are
present: the weakened heart, the dilated vessels and the
slight increase of tension of the eyeball.

Outside of the study of the fundus condition in the above
cases of delirium tremens, the one feature and symptom that
interested me most was the hallucinations that all of them
suffered from — how to account for them. Hallucinations
are the one peculiarly characteristic symptom of delirium
tremens ; and, pertinent to this inquiry, these hallucinations
are almost always visual in character, perhaps in ninety-five
per cent, of the cases, and always in motion. This last fea¬
ture distinguishes them from the hallucinations that occur
in other conditions, when the objects of the hallucinations
are at rest. Not only are the hallucinations of delirium
tremens characteristic from being chiefly visual and in mo¬
tion, but from being confined most of the time to one set of
objects — “snakes.” These, however, may be distorted into
demons or most anything else.

Heretofore, these hallucinations have been attributed to
the psychical derangement from which these patients suffer,
but I think they are due in great measure to another cause
— a circulatory condition. To make my position clear it
will be necessary to call to mind two points in the anatomy
of the retina. First, that the blood vessels of the retina lie
in its anterior layers; they never enter deeper than the
internal molecular layer. Second, the seeing or perceptive
layer of the retina, the layer of rods and cones, forms the
posterior layer of the retina; consequently the blood vessels
are in front of this layer.

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Fundus Oculi in Delirium Tremens . 173

Ordinarily, the retinal vessels are so small and semi¬
transparent that they are not projected into the field of vision
and made visible. But when, as occurs in delirium tremens,
the vessels become passively dilated, tortuous, pulsating and
filled with dark blood, dark enough, as I believe, to be pro¬
jected indistinctly into the field of vision and to be seen,
they appear as “ snakes.” The tortuosity of the vessels
would naturally resemble in shape a snake, and the constant
motion of the blood through them would give the motion
always present in such cases.

With a befuddled brain, these objects could be easily
transformed into any other objects and distorted into end¬
less forms.

The psychical condition of the patient may play some
part in the formation of the hallucinations of delirium tre¬
mens, but I believe the true and main cause lies in the cir¬
culatory condition of the fundus of the eye.

f . DIPSOMANIA AND INSANITY.

The current discussions anent these morbid states ignore
their complete difference. Dipsomania is a true periodical
insanity of which the drink element is a mere phase. The
insane acts are preceded by depression, apathy, and depreci¬
atory ideas. The dipsomaniac period itself is characterized
by tendencies to impulsive homicide in which the nearest and
dearest may suffer. These acts occur in other periodical
insanities entirely independent of alcohol, and hence here
must be regarded as an expression of the mental state, not
of the alcohol, which tinges the mental state. In inebriety
the alcohol is the causative factor. In dipsomania the abuse
of alcohol is a mere expression of the insane tendency.
Dipsomania, as a rule, is one of the degenerative states
demarcable from simple imperative conceptions and inebriety.
During the dipsomaniac period these patients, like all period¬
ical lunatics, are absolutely irresponsible. — Dr. Kernan in
‘‘ Medical Standard.

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174

Abstracts and Reviews.

cLi\d fjeview^.

THE TREATMENT OF MORPHINISM.

In the Bulletin gtniral de thtrapeutiqne there is an arti¬
cle by M. Gilles de la Tourette. According to the author,
there are two methods of treating morphinism, the imme¬
diate suppression of the poison and the slow suppression —
that is, diminishing the daily dose of morphine progressively.
Each of these methods, he says, has its indications. Gen¬
erally, when patients have been in the habit of taking eight
or ten grains of morphine a day, immediate suppression is
the best way, as the other method requires too long a time
to break off the habit.

The patient should be placed under conditions peculiarly
favorable to the treatment. Isolation in a hydrotherapeutic
establishment, with a special physician attached to it, is
essential, as the treatment can be more strictly carried
out there than at home. The patient’s organs should be
examined, for in cases of cardiac affection or angina pec¬
toris immediate suppression may produce syncope. The
digestive canal should also be examined, and the digestive
functions regulated. The hypodermic injections of mor¬
phine must be given regularly, in the morning, at noon,
and at night, as these are the three most important hours
of the day. For this reason isolation is particularly neces¬
sary,' for the habitual tendency of a patient to take a hy¬
podermic injection at any time when he feels the need of
it presents a difficulty hard to overcome. If the patient
has been in the habit of taking fifteen grains of morphine
a day, half the dose only should be allowed on the first
day of the treatment; generally, says the author, on the
first day two-thirds of the dose are suppressed, on the
third day it is diminished to two grains and a half, and

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Abstracts and Reviews .

175

on the fifth day no morphine is given at all. During the
first twelve hours the treatment does not provoke any
troublesome symptoms, and the patient feels comparatively
well. At the end of twenty-four hours, however, the fol¬
lowing symptoms supervene: 1. Syncope, which, if very
serious, is sometimes fatal. If there is no cardiac affec¬
tion, it is of slight importance. For this symptom an in¬
jection of from a grain to a grain and a half of morphine
is given. For vomiting in these cases champagne, iced
grog, etc., are given. 2. Diarrhoea. This symptom should
be carefully observed, for, according to Sollier, the poison
is eliminated by the intestinal canal. There are, however,
cases where the diarrhoea becomes so intense that it results
in true morphine cholera, and in these cases this symptom
must be treated. For maniacal excitation and delirium
soothing spongings or baths are prescribed. During con¬
valescence the diarrhoea should be carefully watched, as it
may persist for three or four weeks, often making it neces¬
sary to resort to the injections. It is the same in regard to
insomnia. If the patient can remain for a month or two
longer in a special establishment, the rest will be a valuable
aid in the treatment. Baths, douches, tonics, and good food
should be prescribed to insure the repair of the physical
condition, and to avoid the troubles of convalescence. The
patient should be weighed, for an increase in weight shows
the beneficial results and a good condition of the digestive
functions. If practicable, it is well to send the patient
away in order to avoid all causes capable of provoking a re¬
turn of the habit.

With regard to slow suppression of the drug, says the
author, this method does not give such good results, owing
to the length of time required for the treatment, which is
from two to three months. It fails, he says, at the least
eight times out of ten. Professor Charcot employed this
method as follows : The patient is made to give up from the
beginning a third of his daily dose of morphine. 2. The
thebaic extract is substituted for morphine ; for example,

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176

Abstracts and Reviews.

for three-eighths of a grain of morphine from a fourth of a
grain to three-tenths of a grain of opium is given, to
which may be added from forty-five to seventy-five grains of
potassium bromide where there is pain in the legs or excite¬
ment.

When the morphinism has yielded to the treatment the
use of the bromide and the opium should be stopped, as they
are no longer useful. It is then a question only of ten or
twelve days before a cure is completely effected.

CANADA’S ROYAL COMMISSION ON THE
LIQUOR TRAFFIC.

The report of the Royal Commission of the Dominion to
investigate the liquor traffic has handed its report to Parlia¬
ment. It consists of several thousand pages of type-written
evidence and testimony. The commission has cost over
$70,000. The commissioners were accompanied by the
attorney of the Liquor Dealers’ Association and traveled
thousands of miles in gathering testimony.

The Rev. Dr. McLeod handed in a minority report. He
gives prominence to the disease, pauperism, waste, and
crime which have resulted from the licensing of saloons.
He says:

“ There is no room for differences of opinion in regard
to the fact that intemperance and its inevitable train of
harmful consequences constitute one of the most formidable
evils that afflict society, diminish the wealth of the country,
and impede progress of civilization. The fact is universally
admitted. Regarding it the commission did not deem it
necessary to prosecute extensive inquiry. In Canada, as in
other lands, intemperance is the prolific cause of pauperism,
disease, insanity, idiocy, excessive mortality and crime, with
all the suffering and sorrow which attend those conditions.”

Dr. McLeod then proceeds to discuss the evidence re¬
garding pauperism, and says : “ Whatever evidence relating

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Abstracts and Reviews .

177

to pauperism was heard in the course of the commission's
investigations in the United States was in agreement with
the foregoing statements, that nearly all of it is traceable,
directly or indirectly, to intemperance."

As to disease, insanity, and mortality, he says : “ There
is a diversity of opinion among medical men as to whether
or not a moderate consumption of alcoholic liquors is in
every case physically injurious. A majority of medical men
unhesitatingly endorse total abstinence as safe. Many claim
that it is essential to the fullest degree of physical health.
All the evidence obtainable goes to show that heavy drink¬
ing is universally condemned, and also that there is a grow¬
ing tendency among medical men to discountenance even
what is known as moderate drinking."

The question, “ Is total abstinence in your opinion com¬
patible with the fullest degree of physical health ?" was one
submitted to 207 medical men in Toronto by the secretary
of the Dominion Alliance, but the commission declined to
receive the statement in reply. Ninety-two replies were re¬
ceived, and the question was answered directly in the affirm¬
ative in eighty-three cases, and of the remaining nine only
three expressed a definite opinion that total abstinence was
not safe for most people, and even they did so in a very hes¬
itating fashion.

Dr. McLeod dwells on the terrible results of the habitual
use of liquor, and points to the replies to questions sent by
the commission to physicians and life insurance companies
in Canada as proof of the physical evils resulting from strong
drink. Of 1,355 Canadian physicians, 1,068 said that the
general health would be improved by total abstinence. Of
1,340 who gave definite answers to a question about moder¬
ate drinking, 901 said that the use of intoxicants even in
moderation is injurious to health and to an active condition
of body and mind. Of 779 physicians a large majority said
that the use of intoxicants increases the number of the insane.
The evidence is quoted to show that not only many drinkers
become insane, but that the mental weakness which under
Vol. XVIII.— 27

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any one of various forms of excitement is liable to become
insanity is in a large degree traceable to the intemperate
habits of the parents.

The question of excessive mortality is fully covered in
the report, which quotes the statement of Hon. G. E. Foster
in Parliament in 1885, that 3,000 deaths per year might
safely be set down to liquor in Canada. Vice and crime, en¬
gendered by strong drink, are also very fully set forth and
sustained by extracts from the evidence. From 1882 to
1892 inclusive the total number of convictions in the Do¬
minion was 383,459. Of these 183,371 were for drunken¬
ness, and probably not one-third of those who drink to
drunkenness ever appear in these records.

A conservative estimate of the amount paid annually by
the consumers of liquors in Canada is placed at $40,000,000.
The cost of prisons, loss of labor, and misdirected efforts
should, Dr. McLeod thinks, be added to the expenditures on
account of the traffic, and he therefore makes the following
estimate :

Amount paid for liquor by consumers, $39,879,854;
value of grain, etc., destroyed, $1,889,765 ; cost of propor¬
tion of pauperism, disease, insanity, and crime chargeable to
the liquor traffic, $3,149,097 ; loss of productive labor, $76,-
288,000; loss through mortality caused by drink, $14,304,-
000; misdirected labor, $7,748,000; total, $143,258,716.

Against this he sets receipts from the liquor traffic as
follows : Dominion government, $7,101,557 ; provincial gov¬
ernments, $942,652 ; municipalities, $429,107 ; total, $8,473,-
316. Net loss, $134,785,400.

Many of the things which might properly be included as
chargeable to the liquor traffic are omitted in the above
statement because of the difficulty of putting them into dol¬
lars and cents. He could add 50 per cent, to the balance
against the liquor traffic, and at the lowest it is so large that
it might well engage the attention of even those who take
no other view of the situation than the business one.

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LUNACY AND INEBRIETY.

We are indebted to Mr. Charles Heneage for a transla¬
tion of two papers on Austrian procedure re curatel, with
persons deemed to be lunatics and habitual drunkards. By
the Austrian Universal Civil Code, par. 21, persons who, on
account of extreme youth, or mental infirmity from any
other cause, are incompetent to manage their affairs prop¬
erly, are placed under the protection of the law. By para¬
graphs 167 and 269, the court has power to appoint a cura¬
tor or attorney for all those unable to guard their own rights.
The Royal Imperial District Court, where the person in
question last resided, receives notice from the parish author¬
ities, or the superintendent of an asylum for the insane to
which the inmate has been admitted on the certificates of a
government physician or of a “ Psychiatrische Klinik,” the
competent tribunal appoints a commission of inquiry, con¬
sisting of a government legal commissioner, two govern¬
ment doctors, and a secretary. The medical experts, after a
period, short or long as the case demands, report in writing,
the legal commissioner appending remarks to the medical
report, to the upper court, which decides whether the cur¬
atel is to be applied. In the first instance the district court
appoints the curator. Legal proceedings to oppose the ap¬
plication of the curatel can be taken, within a time limit, in
the upper provincial or in the Supreme Court. Legal pro¬
cedure can also be taken for the annulling of the curatel,
which is carried into effect on the written report of two
scientifically educated medical experts. Habitual drunk¬
ards, morphinomaniacs, and persons suffering from aphasia
or chronic brain disease are liable to the same procedure.
Professor Schlangenhausen states that the proportion of
habitual drunkards in asylums for the insane varies from 10
to 40 per cent. Drunkards are generally sent to a “ Psy¬
chiatrische Klinik ” or to a hospital for observation, and are
thence transferred to an asylum for the insane. While there
curatel first comes in, as psychologically degenerated drunk-

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ards come under the law, which lays down that curatorship
is required for those who are incompetent to manage their
own affairs and guard their own rights. When the patient
recovers control the curatel may be annulled, though if he
break down it is reapplied by a renewal of the former legal
procedure. In this way some drunkards have been known
to have been put under curatel and to have had it annulled
from ten to twenty times, till either permanent seclusion in
an asylum or death ended their lives. Inebriates are not
proper inmates for an asylum for the insane, as they are apt
to smuggle in drink to the insane, and to have a demoral¬
izing influence on these latter, and as they cannot always be
suitably treated and looked after. Therefore the govern¬
ment have brought forward a bill for the construction of
public asylums for drunkards, to which drunkards can be
sent on the order of a judge, on the application of relatives
or guardians, of a manager of an asylum for the insane, or
of a magistrate based on the written report of experts in
lunacy, the final decision resting with the Supreme Court.
The limit of the period of detention is two years, with a fur¬
ther like period on relapse. If the habitual drunkard have
property a curator must be appointed. Schlangenhausen
thinks that the curatel has aided in the treatment of drunk¬
ards.— British Medical Journal

CONDITIONS WHICH PRECEDE INEBRIETY.

Inflammations, now recognized as proceeding from some
specific causes, are in many cases followed by degenerations
that naturally lead to impulsive demands for relief, which
spirits or other narcotics temporarily supply. Degenerations
from toxemias, and poisons formed both in and without the
body, fall most heavily on the nerve centers, creating the
same demand for relief. Alcohol, while bringing temporary
relief, rapidly increases these very conditions by adding new
toxines, and new and stronger impulses for help. The brain
centers become more debilitated and incapable of recogniz-

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ing the danger, and the degree of actual poisoning becomes
more and more intense.

In many cases there is inherited a feeble power of resist¬
ance, and inability to react and recover from the strains of
injurious agents from without or poisons generated within.
Shocks and powerful emotional changes leave a permanent
impress on the nerve centers. Poisons generated in the
body or the first intoxication from spirits leaves degrees of
degeneration from which there is no recovery. In a certain
number of cases this defective organization shows a marked
tendency to develop into certain forms of degeneration or
disease processes. Inebriety, insanity, and many of the
allied neuroses are common. The tendency to either of
these forms of disease may be seen in certain symptoms far
in advance of its full development. — T. D. Crothers.

TOBACCOISM.

Lewin states that the deleterious effects of tobacco are
observable after its use in any form, — smoking, chewing, or
snuffing.

Typical nicotinism occurs, as a rule, after a long-continued
use of tobacco, sometimes not until twenty years or more.
While many smokers reach old age, many people do not live
to old age because they are smokers.

In nicotinism the skin is the subject of itching and
erythema, the nerves of taste are blunted, an angina grani-
losa develops in the throat, and anorexia, epigastric fullness
and pain, matutinal vomiting and disturbance of intestinal
function are common. There is menstrual disturbance in
women, and in female cigar-makers abortion is frequent.
General sexqal power and appetite are impaired, and some¬
times impotence occurs.

The most frequent pathological effect is disturbed heart-
action, palpitation, rapid and intermitting pulse, praecordial
anxiety, weakness, faintness, and collapse, with sclerosis of
coronary arteries and left ventricular hypertrophy.

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Cigars and cigarettes produce irritation of the nasal mu¬
cous membrane, diminished olfactory sensibility, chronic
hyperemia of the epiglottis and larynx, sometimes even of
trachea and bronchi. Bilateral nicotine-amblyopia is
common, with central disturbance of the field of vision, — a
central, horizontal, elliptical scotoma for red and green, some¬
times, also, for blue in a lesser degree. Often there is
swelling of the auditory nerves and its consequences —
noises in the ear, etc.

Central nervous function is affected. In higher schools,
non-smokers get on better than smokers, children from 9 to
15 years of age who smoke showing less intelligence, laziness,
and a craving for strong drink. Adults are liable to cephalic
pressure, insomnia, or its converse (sleepiness), melancholy
aversion for work, and dizziness.

There may also be atoxic symptoms, paretic weakness of
sphincters, trembling, and spasms. Nicotine-psychoses
are said to rarely affect smokers, occurring more commonly
in snuffers, and still oftener in chewers. The prodromal
stage, which lasts about three months, shows general uneasi¬
ness, restlessness, anxiety, sleepiness, and mental depression
of religious type. After this follow praecordial anxiety, and,
finally, the psychoses proper, consisting of three stages:

1. Hallucinations of all senses, suicidal tendency, de¬
pression of spirits, attacks of frights, with tendency to vio¬
lence, insomnia.

2. Exhilaration, t slight maniacal exaltation, agreeable
hallucinations; after from two to four weeks’ relaxation,
again followed by a maniacal condition.

3. The intervals between exaltation and depression
diminish, the patient becoming irritable, but otherwise not
alive to his surroundings, perception and attention being
lessened.

It is claimed that the patient is curable in five or six
months if he stops the use of tobacco during the first stage.
After the third stage the disease seems incurable. With¬
drawal of tobacco is an essential part of successful treatment.

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Potassium iodide, laxatives, and warm baths hasten elimina¬
tion of the accumulated poison. Subcutaneous injections of
ether are employed against the dizziness; pilocarpine for the
disturbance of hearing; strychnin^ hyoscyamus, biniodide
of mercury, pilocarpine, etc., for the amblyopia.

W. T. Cathell of Baltimore (Dec. 16, ’93), divides tobacco-
users into three classes; those whom tobacco does not
injure, those whom it injures slightly, and those to whom it
is a poison.

The pipe might be the exciting cause of cancer of tongue
and lips. — Annual of Medical Science.

SYPHILIS IN THE MIDDLE AGES AND IN
MODERN TIMES. By Dr. F. Buret, Paris; France,
Translated from the French, with notes, by A. H.
Ohmann-Dumesnil, M.D., Professor of Dermatology and
Syphilology in the Marion Sims College of Medicine;
Consulting Dermatologist to the St. Louis City Hospital,
to the St. Louis Female Hospital; Physician for Cutane¬
ous Diseases to the Alexian Brothers’ Hospital; Derma¬
tologist to Pius Hospital, to the Rebekah Hospital, to
the St. Louis Polyclinic and Emergency Hospital, etc.
Being Volumes II and III of “ Syphilis To-Day and
Among the Ancients,” complete in three volumes. i2mo,
300 pages. Extra cloth, $1.50 net. Philadelphia: The
F. A. Davis Co., publishers, 1914 and 1916 Cherry street.

This is an exceedingly interesting study of a disease
which has caused a great deal of trouble in the world. His¬
torically, it groups a great variety of facts, which revealed the
state of society in the past; and scientifically, it points out
the influence of syphilis in the events of the world. The
peculiar value of this book is the “ side lights ” it pours out
on the ages, and the methods of treatment, and the opinions
of kings, princes, and physicians. Every library should
possess this work.

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184 Abstracts and Reviews .

THE MARVELS OF THE BODILY DWELLING.
By Mary Wood Allen, M.D. The Wood Allen Pub¬
lishing Co., Ann Arbor, Michigan, 1895.

This is a school boo£ of physiology in which metaphor,
parable, and allegory are used freely to make the facts clear
and interesting. While authorities may differ as to the success
of this effort, all will agree that the book is interesting, reli¬
able, and very useful in many circles of society. In the
hands of wise teachers it may be very valuable in school
instruction.

ELECTRICITY IN ELECTRO-THERAPEUTICS. By
E. J. Houston, Ph.D., and A. E. Kennelly, Sc.D.
Cloth, 412 pages; 128 illustrations. Price, one dollar.
W. J. Johnston Company, publishers, 253 Broadway,
New York.

This work is one of a series that are intended to give
clear elementary instruction in electrical problems. This
volume is written for the physician, to give reliable informa¬
tion on the various facts of applied electro-therapeutics.
The electro-technics of apparatus, and the laws of electrical
currents, and some of the facts which are established are
presented with unusual clearness. This treatment of the
subject will be of great value to every physician, because it
deals with facts not in the medical text books, and so covered
up in the larger works on electricity as to be practically
inaccessible. For simplicity and clearness of statements,
and facts that enable the reader to understand some of the
relations of electricity, this book is simply invaluable.

Every asylum and physician who uses electricity should
have a copy of this work, as essential for every-day study.
Everyone who would know some of the facts of this new
problem will find this a great assistance.

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185

DONTS IN CONSUMPTION. A description of the
scientific management of consumption, and how a modern
sanitarium may be had at home, and what means should
be used to assist nature in recovery, etc. By C. W.
Ingraham, M.D., Binghamton, N. Y. Published by the
author at Binghamton, N. Y., 1896.

This one of the few really reliable hand-books, giving
clear, accurate advice to consumptives, that can be com¬
mended. The physican will find many general principles
outlining the treatment of value, and giving him hints that
can be applied in many ways.

While there are many admirable statements and chapters
that should be impressed on all who treat this disease or
suffer from it, the work will bear careful revision, and should
be enlarged and rearranged in many ways. We commend
it most heartily as a decided advance over the shifting un¬
certain therapeutic notions of many physicians.

The value of this work, in many ways, will be inestima¬
ble, especially to intelligent victims of this disease.

THE ANNUAL OF THE UNIVERSAL MEDICAL
SCIENCE. Report of the progress of medical science
throughout the world. Edited by C. E. Sajous, M.D.,
and seventy associate editors. In five volumes. The
F. A. Davis Company, publishers, Philadelphia, Pa., 1895.

This is the eighth issue of an annual which gives the
reader a very complete review of all the new facts which
have appeared during the past year concerning medicine.
The first volume is devoted to diseases of the lungs, heart,
kidneys, also fevers, and all diseases of the blood; the
second is devoted to diseases of the brain and nervous sys¬
tem, also diseases of women and children; the third volume
is devoted to surgery ; the fourth to diseases of the skin, eye,
nose, throat, and medico-legal questions ; the fifth to thera¬
peutics, climatology, and anatomy and microscopy.

In these five volumes the reader can find all the new
Vol. XVIII.— 28

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186

facts and theories which have been urged and defended for
the past year. It is evident at a glance that this is the most
valuable addition which can be made to any medical library.
With these works the physician can see at once what has
been said on the subject all over the world.

These annuals have become established as indispensable,
and no library can be complete without them. Write to the
publisher for a prospectus.

THE DISEASES OF THE NERVOUS SYSTEM. A
text-book for physicians and students. By Dr. Ludwig
Hirt, M.D., Professor at the University of Breslau. Trans¬
lated by August HocHand Frank R. Smith, A.M. (Can-
tab.), M.D., Assistant Physicians to the Johns Hopkins
Hospital. With an Introduction by William Osler,
M.D., F.R.C.P., Professor of Medicine in the Johns Hop¬
kins University. 8vo, 683 pages. With 178 illustrations.
Cloth, $5.00; sheep, $6.oo. New York: D. Appleton
& Co., 72 5th avenue.

This is one of the most readable works on nervous dis¬
eases which we have seen. The clearness of style and fresh
suggestive methods of expression give a charm to a really
difficult subject. There is no padding, no strain to express
the idea in technical words that are unusual, but an easy,
practical flow of simple words that make ideas clear and un¬
mistakable. The arrangement of the various topics differs
from other works, but seems to be a great improvement in
many ways. The author is a master of this subject, and a
thorough teacher, not only of facts, but the relations they
sustain to each other. He is not only a guide, but he points
out new paths of study and roads for the travel of future
investigators. This work has taken place among the great
classics which every physician should possess, — books that
are inseparable to every good library of medicine.

KEY NOTES OF HEALTH AND A CENTURY OF
LIFE. By Dr. C. W. Scott, late professor of anatomy,
Kansas City College, etc., etc. Boston, Mass.: Published
by C. W. Scott, Jr.

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187

This is a volume of much practical information, designed
for both the profession and laymen. It appears to be the
conclusions of a close observer, and one with wide experience
in practical medicine.

THE NATIONAL DISPENSATORY, WITH SUPPLE¬
MENT, EMBRACING THE NEW EDITION OF
THE NATIONAL FORMULARY. The National
Dispensatory. Containing the Natural History, Chemistry,
Pharmacy, Actions, and Uses of Medicines, including
those recognized in the Pharmacopoeias of the United
States, Great Britain, and Germany, with numerous refer¬
ences to the French Codex. By Alfred Stille, M.D.,
LL.D., Professor Emeritus of the Theory and Practice of
Medicine and of Clinical Medicine in the University of
Pennsylvania, John M. Maisch, Phar.D., late Professor of
Materia Medica and Botany in Philadelphia College of
Pharmacy, Secretary to the American Pharmaceutical As¬
sociation, Chas. Caspari, Jr., Ph.G., Professor of Phar¬
macy in the Maryland College of Pharmacy, Baltimore, and
Henry C. C. Maisch, Ph.G., Ph.D. Fifth edition, thor¬
oughly revised in accordance with the new U. S. Pharma¬
copoeia (seventh Decennial Revision) and embracing the
new edition of The National Formulary . In one magnifi¬

cent imperial octavo volume of 2025 pages, with 320 en¬
gravings. Cloth, $ 7.25 ; leather, $8.00. With Ready
Reference Thumb-letter index, cloth, $7.75; leather, $8.50.
Lea Brothers & Co., publishers, Philadelphia and New
York, 1896.

Appleton s Scientific Library is one of the literary events
of the year. There are sixty volumes in all, whose scientific
value is incalculable. Eighteen authors are represented,
among whom are Huxley, Darwin, Spencer, Tyndall, Bain,
Whitney, J. W. Draper, Le Conte, and Proctor, to say noth¬
ing of as many others only less well known but not less au¬
thoritative than these. The books in the library are world-
famous. Spencer’s “ First Principles his “ Principles ” of
biology, of psychology, of ethics; Darwin’s epoch marking

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188

“ Descent of Man ” and “ Origin of Species,” his “Animals
and Plants under Domestication,” and “ Coral Reefs Hux¬
ley’s works, and Tyndall’s; Bain’s “ Education as a Science,”
Draper’s “Conflict between Science and Religion,” Whitney’s
“ Life and Growth of Language,” Proctor’s “ Other Worlds
Than Oursthese are only a few of the books that make
this scientific library so valuable. This is an edition de lux
of the best works of science, that will be a rare addition to
any library. Send to D. Appleton, New York city, for
prospectus.

The Journal of Hygiene continues to bring every month
a rare and most useful table of topics, which are helpful to
every reader.

Appleton s Popular Science Monthly is literally one of the
great magazines of this country. Each number grows more
valuable and indispensable to the thinking readers.

The Scientific American brings every week a rare table of
contents of most stirring work by the leaders of the new
science.

The Homiletic Review is without a rival in the world of
religious thought. Its lessons become more and more valu¬
able and helpful to the readers. Send to Funk & Wagnalls
of New York, for prospectus.

“Blood Purifiers ,” “Nerve Tonics ,” and Alcohol. — The
following so-called “ blood-purifiers,” “ nerve-tonics,” and
other remedies of similar character were recently examined
by the chemist of the Massachusetts state board of health,
with reference to the amount of alcohol contained in them:

Percentage of Alcohol by Vol.

Ayer’s Sarsaparilla, ....*.

. 26.2

Thayer’s Compound Extract of Sarsaparilla,

. 21.5

Paine’s Celery Compound,.

. . 21.0

Hood’s Sarsaparilla,.

. 18.8

Greene’s Nervura,.

. . 17.2

Allen’s Sarsaparilla,.

• • 13.5

Dana’s Sarsaparilla,.

• X 3*S

Brown’s Sarsaparilla,.

• 13-5

Corbett’s Shaker Sarsaparilla, ....

. . 8.8

Radway’s Resolvent,.

. 7-9

These are all vaunted remedies for “ that tired feeling.”

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189

5<ditoVikl.

The twenty-fifth anniversary of the organization of the
American Association for the Study and Cure of Inebriety,
occurs in November of this year. It is proposed to celebrate
it with appropriate ceremonies, a public meeting and dinner.
The same room where the first meeting was held has been
offered for this occasion.

DELUSIONS IN INEBRIATES.

Periodical inebriates often manifest delusions in the free
intervals that are not recognized. In one case the most
miserly parsimony and dread of poverty appears. Every
thought and effort will be directed towards the accumula¬
tion of money, even up to dishonesty, causing distress
among all associates. When the drink period begins he
is generous, kind, and benevolent. The free interval in
another case is a period of contention, suspicion, distrust,
and doubt of the reality of appearances and motives, of every
one. Pessimism in its most aggravated form appears. A
great variety of most complex mental states appear, which
are delusions both transient and fixed. The common form
is the intense religious fervor seen in persons whose drink
craze has subsided. This becomes a burning zeal to rescue
others by what is called gospel temperance work; or more
recently in wild hysterical praise of gold-cure specifics; or
entering upon the work of curing others with unusual cre¬
dulity, by unknown specifics. These delusions always end
in relapse sooner or later. The more prominent they be¬
come the sooner they explode. Recently I had a case, that
after the subsidence of the drink craze, became insanely
slanderous. Nearly all the waking moments were occupied

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in finding dishonesty and falsehood in others. Every hint
or possible act was construed into treachery and baseness.
Corruption was discovered in everything; no one was free
from wrong. There was a peculiar maliciousness and insane
cunning in this that could not be mistaken. The physical
basis for it was manifest in the great improvement from
sharp eliminating treatment, by purging and baths. In
another case sexual delusions of the immorality of others,
and the efforts to entangle the person, would come and go
every two weeks.

Delusions of persecution by friends, relatives, wife, or
parents are also common, but usually unfixed and change¬
able.

These conditions are loosely termed “ crankisms,” but in
most cases are organized and systemized into open or con¬
cealed beliefs. They are always dangerous, because un¬
known, and likely any moment to develop into acts that may
be serious. These delusions are false beliefs which are in
most cases without any foundation or reason from without.
They are the workings of defective cell activities, which pro¬
ject themselves to external objects, apparently governed by
no known conditions. In all probability they exist in all
cases, but are easily corrected and transient in most instances.
After a drink paroxysm the senses are defective, and the
power of analysis weakened. Discrimination between the
true and false is imperfect and misleading. This in most
cases can be called unsystemized delusions, while in others
it is systemized. The mental peculiarities of reformed men
is a new field for the study of these delusions.

CAN AN INEBRIATE BE OF SOUND MIND ?

This question has been recently discussed and answered
in the affirmative, by several authorities who have made a
study of mental disease.

To a specific question of the possibility of a person using
large quantities of alcohol and opium daily for years, and

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191

retaining a degree of mental health and sanity, the answer
was that it was a common occurrence. Instances were
given to illustrate and prove this fact. The evidence of
these statements were found to be based on general obser¬
vation and the opinions of the inebriates themselves or their
friends. Why should the assertions of persons who have
paralyzed themselves for years with alcohol and other nar¬
cotics, be accepted as evidence of sound mind, simply be¬
cause it sounds reasonable ? Why should the statements of
such people be accepted without critical inquiry and exami¬
nation in the same way as thfc assertions of persons notably
insane are studied ?

The conduct and opinions of inebriates are pre-eminently
subjects of critical study, because the toxic causes are fully
recognized. The reason that this is not done in all cases,
is the prevalent opinion that alcohol and other narcotics are
harmless in small doses, and taken in moderation.

It is impossible at present to draw lines where any drug
ceases to be harmful, and say that up to this point it is safe
and beyond it is dangerous. The inebriate has visibly poi¬
soned himself; the fact that he displays no common symp¬
toms of insanity or pronounced mental unsoundness is no
evidence of mental health.

Serious diseases exist which do not manifest themselves
in the ordinary changes of conduct and character. Mental
soundness is not established by the presence or absence of
certain fixed symptoms. The central fact that alcohol or
other narcotics are used daily, is always evidence of two ab¬
solutely certain pathological conditions. One degeneration
of the higher brain centers, manifest in the continuous use
of these drugs. The other, paralysis of all the functional
and psychical brain processes.

The continuous action of alcohol and opium, depressing
and diminishing cell activities, causing complex changes,
chemically and physiologically is always incompatible with
mental health. The demand for spirits or drugs, whether
explained by any reasoning or possible motives, is always

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Editorial.

abnormal and inconsistent with health. It may come from
error of judgment in the person or his advisers, but soon it
becomes a pathological state, growing more and more fixed
Theoretically and practically no inebriate can be of sound
mind. Cases that are held up as examples of persons who
have used spirits for a lifetime, will not bear the test of
critical examination. It is extremely doubtful if any such
persons exist ; all the examples of persons who have used
spirits twenty years or more are found to be unsound in both
mind and body. Up to the present time no exceptions have
been noted. The fact that little change in character and con¬
duct was apparent to superficial observation is no evidence.
An inebriate who boasted of his immunity from disease from
alcohol, was found to have neuritis cirrhosis, mental delu¬
sions of suspicion, and illusions of spirits guiding him.

Any careful study of such cases will furnish abundant
facts of disease and mental unsoundness. The medical au¬
thority who doubts this, has simply to appeal to the facts
for evidence which is accessible and convincing.

INEBRIETY IN INFANCY.

Recently a neurologist denied the possibility of the alco¬
holic craze in young children, and asserted that it could not
be proven by actual clinical cases. The Journal of
Inebriety has published a number of such caaes, and other
journals have noted similar instances.

While these cases are rare, or, at least, have not been
observed very often, they exist is homes of the wealthy as
well as the very poor.

I have met some cases like the following: A boy, two
years old, in the family of a wealthy man, who had been
kept from tasting any form of spirits, suddenly became
intoxicated. He drank a glass of wine found by accident.
From this time he was a literal dipsomaniac, whose excessive
irritability could only be quieted by some form of spirits. No
medicine could take the place of spirits. Medical skill was

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193

unavailable; nothing would quiet the excitement and nervous
tension but alcohol.

This was concealed in various ways, but the constitutional
proclivity for spirits refused any other means for relief.
After two years of persistent effort, the father abandoned
all other drugs and gave spirits regularly every day. The
child died at eight years of some obscure fever. The father
called this a judgment on him for continuous drinking up to
the second year of married life, when his wife died, and he
partially refrained from all spirits. Such cases are fortunately
not common, but the facts they bring out exist in many ways
unobserved.

Examples are moderate drinking parents, who use wine
on the table, and who insist on total abstinence in children,
or permit them to drink small quantities. Such children
may suddenly become intoxicated, or develop a craze for
spirits, and, after a period of semi-delirious excitement,
become chronic inebriates, or die from some intercurrent
disease. This craze may appear in infancy and in early
childhood, and be covered up by the parents and physician,
until death (which usually comes early) closes the scene.

In the very poor the same conditions follow, only the
craze seems more dependent on physical conditions and less
concealed.

I have seen three cases in children under five years of
age, who possessed a maniacal desire for alcohol. One was
in a wealthy family, the other two were in mechanics’ homes.
The parents in all these cases were moderate and excessive
drinkers. One child died of pneumonia, the others I have
been unable to follow.

I have, through consultation by letter and statements of
other persons, heard of a number of cases where this desire
for spirits came on suddenly and was a veritable dipsomania.
The experience of physicians who see many cases of children
confirm this fully. Often a class of most puzzling symptoms
in children suddenly disappear, from the use of alcohol,

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which may be concealed or combined in some form of a
tonic.

After a time it will be apparent that the alcohol is the
only drug of value.

Some inherited defect has been awakened, and the
imperious demand for relief will not be satisfied with any
other drug. Inebriety exists in infancy as an inheritance,
as a transmitted form of degeneration, which rapidly runs its
course. Of course inebriety can be very easily acquired in
early life, but its duration is longer, and the antagonism of
growth and development retards its progress until maturity.
The inebriety of infancy or early childhood is of short dura¬
tion, and always an inheritance that ends in early death.

There is no doubt that many cases of this kind are con¬
cealed from observation, and that inebriety in infancy is
more frequent than it is supposed to be.

LANGUAGE SYMPTOM IN ACUTE INEBRIETY.

The effect of alcohol and other drugs on language and
power of expression varies widely. A study of a number of
cases indicates a general uniformity in the defects of selec¬
tion, and capacity in the use of words, which is possible to
group and compare. The first action of alcohol in suddenly
increasing the circulation of the blood to the brain is appar¬
ent in an alteration of capacity, of expression, and change of
common language. This is often noted by a tumultuous
flow of words, which begins along natural lines and merges
into confused statements, with an increasing number of
adjectives.

In other cases language changes at once, either to ex¬
tremely coarse violent words, or to most deferential polite
expressions. After a short time the power of expression
becomes palsied, and only confused expletives and negations
continue.

In certain cases a marked aphasic condition begins in the

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first stage of drinking and continues to a nearly total loss of
words.

Such cases are not stupid, but seem adverse to all pow¬
ers of expression, and, when forced to use words, select the
briefest expletives.

Another class seem to have no power of selection in the
use of words beyond the terms which express the lowest
animal impulses. They repeat such terms over and over
again, manifesting satisfaction at their sound.

Nearly all inebriates suffer from exaltation and deliriums
of mental vigor and power. This is dominant in language,
which is often bold and extravagant in words.

Often a consciousness of the effects of harsh words are
realized, and a shrinking or increasing boldness in their use
is manifest.

The mind has not lost its power of selection altogether.
Fear or other motives rouses a degree of restraint in words
that are remarkable at times.

When extreme volubility appears there is confusion of
ideas, beyond boasting of power, and wild, strange adjectives.
Language ceases to become mental expressions of anything
beyond the lowest animal impulses. This may take on
sexual phases, wild combativeness, or miserly selfishness,
with suspicion of wrongs from others. Coarse, unguarded
words express these impulsive or localized irritations of cer¬
tain brain centers. In one case wild, threatening words,
that seldom merge into acts, are seen. Often these violent
expressions are overcome by opposition and fear, or they
become intensified into true deliriums. If the sexual brain
centers are affected, the language expresses this. Often
the concealed, miserly impulses burst out in words at this
time. The language is not an expression of the normal
condition of the man, but only of some state of general or
local paralysis, which may have been existing for some time.

Deliriums of exaltation and grandeur, or of melancholy
and depression, manifest in words at first natural and con-

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Editorial .

nected, then confused and vague, are common to many
cases.

Aphasic states, where words and expressions are used
without conception of their meanings, are also common.
An instance is that of a business man, who wrote while
intoxicated, using words which conveyed a certain meaning
to him entirely foreign to their real import.

Extravagant use of words in all circles of life attracts atten¬
tion to the mental condition. Where alcohol and opium are
used defects of powers of expression and conceptions of the
value and force of words are common to all cases. In some
this is very prominent; in others the finer shades of word
palsy are only noted by study. Some very startling facts
will appear from a comparative study of this symptom in
inebriety.

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Clinical Notes and Comments.

197

dlii\idcil j\fote$ cir\d Comment^.

CASE OF HEREDITY.

Dr. McClelland, in an excellent essay on “ Heredity versus
Education,” gives the following very remarkable study of a
case:

“A distinguished judge of Kentucky was for a long time
a secret drinker, then became openly addicted, and died from
the effects of drink. He had three children, one daughter
and two sons. One son died in infancy of convulsions.
The other, at the age of 19, was sent to an insane asylum.
The daughter married a healthy, temperate man, then
became an inebriate and died from the effects of drink. She
left six children, two sons and four daughters. One son
committed suicide at forty-two years of age. The second
son, a physician, was a passionate, misanthropic man, who
married and had two children; then broke off all family
relations. One daughter is a neurotic, and has hysteria;
two other daughters are unmarried, and, while intelli¬
gent, are considered queer. The fourth daughter was un¬
usually well-developed, handsome woman, who married hap¬
pily to a temperate, healthy physician, who lived a long life of
great regularity. Six daughters and one son came from this
marriage. One of the daughters was feeble minded from
infancy, and was finally burned to death by accident. A
second daughter had intermittent attacks of insanity. The
youngest daughter committed suicide by throwing herself
out of a window. The son became a successful physician,
but developed inebriety.”

The history of this family is as follows : The first gener¬
ation, alcoholic excess. The second generation, insanity and
dipsomania. In the third generation, hypochondria, suicide,
mania, and hysteria. In the fourth generation, imbecility,

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Clinical Notes and Comments .

mania, insanity, and dipsomania. In the fifth generation,
one of the children has already evinced unnatural cruelty
to animals. This exhibits a wonderful tenacity of hereditary
transmission of degenerative qualities.

INTOXICATED OR DYING?

Of the numerous cases in which the physician is called
upon to express a diagnosis, and prescribe treatment, there
are none, we believe, more difficult to decide on than those
of persons found insensible in the streets. Very frequently
there are cases of simple poisoning from excess of alcoholic
drinks, especially of an adulterated and deleterious nature,
but at times there are cases of disease, or of disease compli¬
cated by head injuries, which, if not promptly recognized and
treated, may ultimately prove of a serious nature. We are
prompted to refer to the liability of errors in diagnosis of
such cases, and the necessity of great caution in dealing with
them, by the not uncommon occurrence of them, and the fact
that they frequently become public, and excite a good deal of
comment in the public press. A young man is found in¬
sensible in the street; is taken by the police to the nearest
station ; and is there seen by the medical officer in charge,
who gives as his opinion that the insensibility is due to alco¬
hol. In the morning more serious symptoms show them¬
selves, and medical treatment is resorted to, but unfortunately
without avail. A post mortem examination reveals that apo¬
plexy was the cause of death. In another case a man is
brought by the police to one of the hospitals, is admitted
there, and after a few hours is once more sent back to the
police station as suffering from an excess of alcohol. Soon
after his return to the police station it is observed that his
condition is not satisfactory; the police surgeon is summoned,
and he gives it as his opinion that the man is suffering from
some serious head injury, and sends him back to the infirm¬
ary from which he had been dismissed only a few hours
previously. Such incidents as these cause a painful im-

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199

pression on the public mind, and are calculated to destroy
public confidence in the ability of professional men to recog¬
nize what is, and what is not, drunkenness, to say nothing of
the serious consequences that must accrue to a patient
suffering from some disease or injury of the brain from being
thus conveyed through the streets at that early period of his
illness, when prompt medical treatment might prove of some
avail. We can only say, that such cases should serve as an
instructive lesson to all those who are connected with the re¬
ception of patients at our infirmaries, and should impress on
physicians generally the advisability of erring on the safe
side, and of not giving a positive diagnosis in any case about
which there can be a shadow of a doubt. — Editorial Mass .
Medical Journal .

Dr. Lobias of Coatesville, Ind., writes in September
Courier of Medicine as follows, on spirits in typhus fever:

“ Of what use is alcohol in medicine ? We have a better
heart tonic in digitalis; as a lung tonic a vastly better in
strychnine ; nitrate of amyl acts quicker; atropine warms
up better. To tide over a dangerous time we would prefer
iron, quinine, and strychnine, concentrated food, and atten
tion to hygiene. Is it capable of prolonging life or in any
way assisting nature in throwing off the microbes of disease ?
The most extravagant claims have been made for it by the
laity. It is the one panacea for all the ills to which the
human flesh is heir. But when we come to look at its
effects in a fair and impartial manner, do not its claims as a
therapeutical agent rest on a very unstable foundation ?
It prevents oxidation of the tissues. Physiologists tell us
that when taken into the system the effect of alcohol on the
red blood corpuscles — which are the oxygen carriers — is to
lessen their power of giving off oxygen, and in this way the
oxidation of tissue is interfered with. It does not require
any great stretch of the imagination to see that while this
condition of inactivity exists, all the organs of the body must
suffer, for any interference with the supply of oxygen will

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Clinical Notes and Comments.

necessarily interfere with evolution of force. In Flint’s
Physiology it is said : ‘ Alcohol is capable of being absorbed
and taken into the blood, but that it passes out again un¬
changed. It cannot be regarded as an aliment, and hence
cannot take the place of articles that are assimilated.’ The
fact that those who indulge in alcoholic liquors are unable to
endure the same amount of fatigue, is conclusive evidence
that alcohol is in no sense a food. Men have been enabled
to endure the extremes of heat and cold much better without
alcoholic liquors of any kind than with them. The effect of
alcohol on the human organism, in either health or disease,
is unfavorable, as its use tends to increase the risk of infec¬
tions in contagious diseases, and the progress is rendered
more grave because of diminished resistance on the part of
the organism in either health or disease. It is perfectly safe
to predict that the time is not far distant when it will be as
rare for a physician to prescribe alcohol as it is now for him
to prescribe blood-letting, and when a healthy man will no
more think of taking alcohol, with a view of preserving
health, than he would strychnine for the same end.

MORPHINISM IN CHILDREN.

Dr. J. B. Mattison of Brooklyn read a paper on this
subject in which he stated that although the literature of this
subject was extremely scanty, he believed that the condition
was not very uncommon in children. Among the illustrative
cases was the following remarkable one: A baby of seven
months when first seen presented the shriveled and wrinkled
appearance of an old man, and attracted one’s attention by
its peculiar, solemn manner. It was learned that the child
had been perfect at birth, and had thrived up to the age of
four months, when in order to quiet it when fretful it was
given paregoric. It very soon became necessary to give
laudanum, and also to increase the dose, so that when first
seen by the physician, it weighed only seven pounds, was
shockingly emaciated, and extremely weak. It was taking

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Clinical Notes and Comments .

201

at this time no less than one ounce of laudanum daily. The
laudanum was reduced one drop at each dose, and at the end of
one month the child had become plump and well again. The
speaker said that there were those in the profession who in¬
sisted that the chief factor in the causation of morphinism
was moral obliquity, but cases like those just cited were in
themselves sufficient to show that this theory was wholly un¬
tenable. In this experience, children showed a very strong
tendency to become victims of morphinism. The consequen¬
ces of this habit in the young were speedy decline and death,
if not promptly treated ; but if there were no structural lesion,
and nutrition had not been too greatly impaired before com¬
ing under treatment, every case could be cured by judicious
management. It was, in his opinion, monstrous to think of
withdrawing the morphine abruptly in adults, and certainly
it should not be thought of in children. The gradual with¬
drawal of the drug together with general tonic measures con¬
stitute the whole treatment. His' reason for thinking that
morphinism was much more common in children than the
literature would seem to indicate, was the extensive and
reckless use of many nostrums for the children, nearly all of
which contained opium in some form. If the physician would
instruct mothers regarding the great risks incurred in using
all such preparations for their children, and at the same time
the sale of these nostrums were under national or state con¬
trol, much would be accomplished in the way of mitigating
this terrible evil.

Dr. J. H. Fruit night said, that in an extensive experience,
he had never encountered the congenital form of morphinism
in the young, but he had frequently seen the acquired form,
as a result of dosing them with soothing syrup and cough
medicines.

Dr. E. A. Tucker said that he had seen one case of con¬
genital morphinism in the hospital. It was the offspring of
a mother, who, for several years previously, had been addicted
to taking morphine, and also to smoking opium. At birth
the child appeared to be perfectly healthy, but when handed
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Clinical Notes and Comments.

over to a wet nurse it began to lose ground rapidly. This
he had attributed to the sudden removal of the baby from
the influence of the morphine to which it had been subjected
in utero . In the future, he would be disposed to try the effect
of giving the child for a few days after birth small doses of
morphine, and gradually withdrawing it altogether.

The chairman described a case illustrating the difficulty
in many instances of determining positively that the child is
a victim of this drug habit. A child who had been unusually
docile and free from excitement while under the care of the
nurse, suddenly became almost maniacal when the nurse was
called away for a day or two. This outburst was evidently
due to the child being suddenly deprived of the drug.—
Pediatrics.

HYDROCYANATE OF IRON (TILDEN’S) IN EPI¬
LEPSY. By X. T. Bates, M.D., Glade Spring, Va.

Epilepsy is termed an affection of the nervous system,
dependent on many causes, and pronounced very intractable
if not incurable in the great majority of cases. The more
subtle and occult the cause, the more obstinate has been the
disease usually, and the more unpromising and unfavorable
is the result.

The ordinary approved methods and remedies in my ex¬
perience have been signal failures, their effect being to pro¬
duce and hasten the very mental disturbances and physical
decay which the disease itself likewise is sure to induce. And
in the treatment of epilepsy it is with great satisfaction that
we may leave the old beaten track, turning away from the
demoralizing bromides to the adoption of hydrocyanate of
iron, which has a benign and reconstructive influence on the
system, being pre-eminently a neurotic tonic and valuable in
other diseases than the one under our consideration, particu¬
larly dyspepsia, gastralgia, neuralgia, and anaemia appearing
in neurosthenic subjects.

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Clinical Notes and Comments .

203

Hydrocyanate of iron (Tilden) some years ago enjoyed
quite a reputation in the treatment of epilepsy, engaging the
serious attention of many physicians, and its merits along
this line elicited considerable literature, but for some reason
it did not bear out their sanguine expectations, and conse¬
quently fell into disfavor and comparative disuse as a remedy
to combat this disease. Of late it has been revived, and
again it has come to the front, fulfilling its earlier promise.
The maximum value of every remedial agent depends largely
upon the perfection of its preparation, and the fact that this
medicine now proves more effective and reliable than hereto¬
fore may be owing to improved methods of manipulation in the
laboratory whereby the manufacturing chemist can supply a
better article than formerly. My own experience with hy¬
drocyanate of iron has been most gratifying, and I believe it
may well be our primary dependence in all cases of epilepsy
save those that come within the realm of surgical interference.
I give the following case, which, in this connection, seems
to me of special interest and worthy of report in detail, since
it had so long baffled all treatment and yet so readily yielded
to the hydrocyanate of iron.

A. B., male, aged 35 years, resident of Kansas, occupa¬
tion house-painter, which he had followed for only two years,
when he felt compelled to abandon it in consequence of fre¬
quent and prostrating epileptic seizures, thinking, possibly,
there might exist between his vocation and his sickness the
relation of cause and effect.

Later he engaged in the real estate business, but shortly
was obliged to relinquish this also. The attacks had regular
periods, coming on every ten days, and were very severe
from the outset. In the convulsive stage he would froth at
the mouth, bite his tongue, and finally lapse into a quiet, un¬
conscious state, in which he would remain from six to ten
hours. With the return of consciousness he would be semi-
dazed, and this condition would last for several days, during
which interval he suffered with a dull headache. Sometimes
eight or ten convulsions would follow in rapid succession,

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Clinical Notes and Comments .

and then he would be confined to his bed continuously for
three weeks.

The history of this person traces his epileptic state to no
traumatic origin, nor does it reveal any habit, condition, or
inherited tendency sufficient to account for the disease. He
was apparently in perfect health when first stricken down.
The subtle undermining influence at work in his system may
be termed “ idiopathic,” the least understood and the most
difficult to overcome.

The initial seizure was in 1888. He has been treated by*
several physicians, one of whom was a specialist in New
York. The paroxysms were so persistent, obstinate, and
progressive both in severity and length of duration, that his
medical advisers ceased to give him encouragement, and
finally he relinquished all treatment, and came East in 1894
in the hope a change of climate might benefit him. He did
this as a dernier resort . After having been among the moun¬
tains of Virginia for a few months he noticed that the parox¬
ysms, though recurring just as regularly, were somewhat less
pronounced, and this revived his hope and renewed his grip
on life and prospective business. But his encouragement
was of short duration, for soon the paroxysms, instead of be¬
ing confined to the night season, began to appear without
warning during the day also. Disappointment and despond¬
ency now came over him because he was forced to the con¬
viction of a gradual decline instead of a radical improvement.
His brief and delusive hope was to be accounted for, no
doubt, by the kind attention of friends, such as he had not
heretofore received in the West. Here they watched him
night and day, and would change his position whenever they
observed him going into a fit, which would have the effect to
modify the attack. From the first his appetite was impaired,
bowels constipated and confined, and a purgation was re¬
quired about once a week. Continuously since the first
attack his body has been covered with yellowish blotches
about an inch in diameter, which would assume a deep orange
color just previous to his taking on a paroxysm.

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Clinical Notes and Comments .

205

Patient can give no information as to what the drugs were
which he had taken. They always were liquids of a salty
taste, and presumably they were bromides. He first con¬
sulted me October 20, 1895. I prescribed :

R. Hydrocyanate of iron tablets, 1-2 gr. each (Tilden’s).

S. One tablet before meals, and as a digestion I ordered
Elixir Maltopepsin (Tilden's) after meals.

At this time the paroxysms were severe and coming on
regularly every ten days, and their effect was perceptible on
•the countenance, which, naturally strong and vivacious, had
become dull and expressionless. His memory, formerly
good, was now very defective, and from day to day he could
barely recall the names of new acquaintances. His whole
physical system was decidedly weakened, and his mind com¬
paratively inactive. His native ambition and will power had
greatly degenerated, and he was indolent, inclined to eat and
lie down, manifestly lacking disposition to take the exercise
his health required. In the early part of 1895 he was offered
an excellent position in a neighboring city, but he had no
energy to avail himself of it.

Before taking my treatment he was nervous and restless
every night until toward morning, when he would fall into a
deep slumber, breathing heavily, and would awaken with a
headache.

December 2d, and frequently since coming under my
charge, he has called on me, always reporting progress and
exemption from his convulsive attacks, though stating that
at regular periods he would have slight monitions of the
same, such as a momentary dizziness or passing headache,
symptoms just enough to make him apprehensive.

January 1, 1896. About this time I ordered an* additional
tablet at bedtime. The concurrent testimony of his imme¬
diate friends is that he is markedly improved both physically
and mentally, and he is now applying for a business situa¬
tion. His facial expression and entire physique have under¬
gone such alteration for the better as to elicit favorable com¬
ment from the most casual observer, and he declares himself

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Clinical Notes and Comments.

“ made over new.” His appetite is good, his flesh harder,
his weight much increased. He now sleeps easily as a child,
with no labored breathing, and awakens rested and re¬
freshed.

January 15th. The blotches referred to have entirely dis¬
appeared, and he has had no severe convulsion since the
commencement of my treatment. His only convulsive attack
occurred December 27, 1895, and was a very light one and of
short duration, from which he rallied quickly. The spell now
seems broken, for since this there have been no symptoms*
whatever, and he is now engaged as “weighmaster ” and as¬
sistant bookkeeper in a large manufacturing plant, having
entered upon this position January 9th. In his own confi¬
dence he has assumed these business responsibilities without
my consent or approval.

I shall advise the continuance of present treatment for at
least the space of twelve months, never deeming it wise in
epilepsy to relinquish combative measures within a shorter
period than this after the malady has ceased to manifest
itself.

Listerine has become a standard drug which is recog¬
nized in every section of the country.

The Rio Chemical Company will send a trial bottle to
any one who wish to test Celerina as a mild sedative and
tonic in various affections.

We call especial attention to an article on Hydrocyanate
of Iron y prepared by Tilden & Co., New Lebanon, N. Y.

It is a. pleasure to call attention to the new preparation
of Reed & Carnrick of New York, called Protonuclein.
It appears to be a most valuable medicine in many cases,
and worthy of a more extended trial. The well-known
character of the firm, as manufacturers of reputable drugs,
brings great confidence to any preparation which they offer
to the public.

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Clinical Notes and Comments . 207

We use large quantities of Acid Phosphate , and find it is
unique and invaluable in many cases, and without substitute
in therapeutics.

The various Maltine preparations , some of which we
advertise, have come to stay, and will go down far into the
coming generation as standard remedies for the next genera¬
tion.

The various preparations of the W. H. Schieffelin & Co.,
particularly Trional\ Sulfonal , and other new products, are
without rivals in the market. Trional is a great standard
drug whose use is increasing daily.

The famous spring water called Arethusa, put up at Sey¬
mour, Conn., increases in value wherever used.

The Tissue Phosphates of Wheeler's formula, is a pecu¬
liar nutritive tonic of great usefulness.

The drug Antikamnia has come into very general use,
for its value in controlling pain with the least disturbance to
the general system. It possesses other.powers in thera¬
peutics of great value. #-

The curative power of Fellows’ Hypophosphites is
clearly attributable to the combination of iron, manganese,
lime, potash, quinine, and strychnine.

Bromidia , Papine , and Iodia are three medicines pre¬
pared by Battle & Co., that are invaluable to every general
and special practitioner.

Parke , Davis & Cols , new compound for all forms of
dyspepsia, is of great practical value, and becomes a favorite
remedy wherever used.

We call attention to a new remedy of great power, the
Arsenauro, which is worthy of the closest attention.

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A Private Hospital for the
Special Treatment of Alcohol
J and Opinm Inebriates.

T HIS Institution was founded in 1878 on the modern view that Inebriety is
a disease and curable. Each patient is made the subject of special study,
and special medical treatment suited to the exact requirements of the case. The
general plan of treatment is building up the diseased organism and restoring
both mind and body to a healthly and normal condition, with brain and nerve,
rest , etc. This is accomplished by Turkish , Russian , and Saline jfaths.
Electricity, Massage , tonics, diet, and every other means known to science and
experience which have proved to be of value in these cases.

This Hospital is pleasantly situated in the suburbs with the best surround¬
ings, and every appointment or an elegant residence.

Experience proves that a large proportion of cases who come under treat -
ment, and who unite with the physician in the use of all means of treatment*
are permanently restored and cured. Each case has the direct personal care
of the physician and attendant; and no one is received for less than four
months unless by special arrangement.

All letters and inquiries should be addressed,

T. D. CROTHERS, M.D., Hartford, Conn.

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THE

Quarterly Journal of Inebriety.

Subscription, $2.00 per year.

Vol. XVIII. JULY, 1896. No. 3.

This Journal will not be responsible for the opinions of contributors, unless
indorsed by the Association.

THE USE OF COCAINE AND ACCIDENTS' RE¬
SULTING FROM IT —PHYSIOLOGICAL AC¬
TION*

By Doctor E. Delbose.

Cocaine has been regarded as a general anaesthetic, but
this view cannot be maintained from more intimate knowl¬
edge of its physiological qualities. It can be likened to no
other medicament, except, perhaps, morphine.

Local Action ,.—When a solution of cocaine is applied to
the naked skin, to the mucous surfaces, or is injected sub¬
cutaneously into the cellular tissues, the tegument in con¬
tact with the liquid becomes pale, assumes a livid tint, and
becomes soon insensible to pricks. Three minutes are suf¬
ficient to obtain this result, and all parts impregnated with
the solution may be cut or torn without the subject experi¬
encing any pain. The sense of touch , however, is preserved,
that of pain only suppressed. In one word, it is a simple
analgesia.

This partial insensibility was at first regarded as a
secondary phenomenon. The first effect of.cocaine was to
provoke a contraction of the coats of the blood vessels, and

* Translated from La Clinique.

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210 Use of Cocaine and Accidents Resulting from it.

the sensory nerve cells, insufficiently nourished, lost their
physiological functions.

Arloing has proved that these two phenomena are ab¬
solutely independent.

He attributes the anaemia, the paleness of the tissues, to
an excitation of the vaso-constrictor fibres of the grand
sympathetic. It is enough to cocainize the eye of a rabbit
and then to cut the cervical sympathetic, to see an enormous
vascularization of the conjunctiva follow the anaemia of this
membrane. And, nevertheless, the eye remains insensible .
Hence the analgesia cannot be attributed to the constric¬
tion of the vessels.

Arloing believes in a direct action of cocaine on the
terminal sensory fibres. And this opinion is not a simple
hypothesis; it is based on the following experiments:

A fragment of the sciatic nerve of a frog is immersed in
a strong solution of cocaine. The nerve becomes yellowish
brown, and on miscroscopic examination the whole contents
of the nerve fibres are found to be coagulated. Another
piece of nerve immersed for the same time in distilled water
shows no coagulation, save in the neighborhood of the
sheath of Schwann. It must, then, be admitted that co¬
caine acts by disintegrating the protoplasm of the nerve
elements.

Besides this, it is to be noticed that, in a mixed nerve,
the sensory fibres are the first to be attacked; the motor
fibres are so only secondarily. Feinberg has shown that co¬
caine applied to an exposed nerve produces a local anaes¬
thesia which is propagated to the periphery, while the cen¬
tral end of the nerve and its motility remain intact.

Sometimes, after a local application of cocaine, a general
analgesia of the whole surface is obtained. Laborde> who
first noticed this phenomenon, offers no explanation of it;
he is content to observe that the nervous system is not in¬
fluenced, “for the excitability of the nerve trunk is pre¬
served and even increased/’ Brown-Sequard thinks that
this phenomenon must be allied to that case cited by Ricket

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Use of Cocaine and Accidents Resulting from it . 211

in 1846, where a simple cauterization by red-hot iron pro¬
duced an analgesia, not only of the point touched, but of
the entire body.

To sum up, and without troubling ourselves with this
inexplicable and very rare phenomenon, we may say that
cocaine, applied to a mucous surface or injected into the
subcutaneous cellular tissue, suspends the physiological
functions of the sensory cells with which it comes in con¬
tact. A weak solution of the alkaloid is sufficient to pro¬
duce the result. Thus a centigram of the salt in solution,
injected into the derma, will give a perfect analgesia of all
that portion of the derma bathed by the liquid.

General Action ,'—Besides these purely local effects, co¬
caine, under certain circumstances, may give rise to general
phenomena which are often very remarkable.

The evolution of these phenomena is subject to diverse
causes.

The quantity of active substance has naturally a prepon¬
derating influence. A certain dose will produce a simple
excitation, while a little larger dose will provoke convul¬
sions.

The method of administration is important. Thus, taken
by the stomach, an animal will be able to absorb with im¬
punity a quantity of cocaine that, injected into its cellular
tissue and, above all, into its peritoneum, would produce
alarming general symptoms; and this same dose, injected
into a vein, would surely cause death. The quantity of
active substance is then relative; all depends on the rapid¬
ity of the absorption.

The kind of animal experimented on is also of great im¬
portance. A fish, for example, does not react in the same
manner as a dog. The former, having regard to the pro¬
portions, resists a dose of cocaine that would infallibly kill
the latter. We shall endeavor to explain these differences,
for in them we believe lies the interesting point of this
general action.

In 1879, Anrep studied the physiological effects of co-

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212 Use of Cocaine and Accidents Resulting from it.

caine, and he was the first to point out the action of this
substance on the nervous centers. He had seen that co¬
caine increased at first the excitability of the subject. This
first action is manifest in a warm-blooded animal, and ap¬
pears to be absent in cold-blooded ones.

On injecting under the skin of a frog a solution of co¬
caine, we see for two or three minutes the animal become
agitated and jump about with no apparent reason. But this
excitement is fugitive, for it soon ceases and we only see a
sort of flaccid paralysis. There still remains, however, an
exaggeration of the reflexes, indicative of excitability of the
spinal cord. But this excitability may be rapidly exhausted;
it is true that it is regained almost as easily. In fact, the
animal reacts less in proportion as one multiplies the excita¬
tion, but if we let it be an instant it responds with as much
energy as ever to new excitations.

On a warm-blooded'animal this primary action of cocaine
is most manifest. A rabbit, for example, will commence to
run of its own accord; if it stops, it is enough to touch it
gently to see it start out again. When the dose of cocaine
is too strong, the excitability increases rapidly and convul¬
sions ensue. From this moment we obtain truly toxic
effects. We might, perhaps, term a “physiological dose”
the dose of the alkaloid capable of simply heightening the
physiological functions of the animal without disturbing
them; that is to say, without giving rise to convulsions.

But at the same time other phenomena are produced
which have all the same origin.

Thus Vulpian has noticed in the dog a protuberance of
the eyeballs, mydriasis and swelling of the eyelids, results
absolutely the same as those we get by electrifying the
superior end of the cervical sympathetic when cut. Vulpian
believed that cocaine excited first of all the cervical origins
of the sympathetic. This excitation had, as a consequence,
a constriction of the blood vessels, which allowed him to
understand the elevation of blood pressure. This elevation
followed the primary lowering of blood pressure due to a
direct effect of cocaine on the walls of the heart.

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Use of Cocaine and Accidents Resulting from it, 213

Laborde believes also in an excitation of the vasocon¬
strictor fibres of the grand sympathetic, for he has always
observed in the rabbit anaemia of the auricular vessels.

The excessive frequence of the heart beats may be ex¬
plained in the same manner. Thus all these phenomena,
joined to the reflex hyper-excitability, are indubitable proofs
of the action of cocaine on the spinal cord.

But the other parts of the cerebro-spinal axis are equally
influenced. We naturally think of the medulla oblongata
to explain the modifications in the respiratory rhythm, and
of the cerebrum to explain the irresistible motor impulse
which animates a cocainized animal.

It is well to remark that this action on the brain is much
more manifest in man, whose psychic faculties are notably
increased and often disturbed.

From all these facts we may conclude that cocaine in its
physiological dose is an excitant of the cerebro-spinal axis
with predominance perhaps of the medulla.

When we pass this physiological dose which we shall
farther on endeavor to determine, we see convulsions ensue,
which, tonic at first, becomes rapidly clonic. The animal
does not always succumb. Recovery depends on the quantity
of the alkaloid; hence the possibility of administering a con¬
vulsive dose which shall not be a mortal one.

But why convulsions ?

Laborde believed that they were due to excitation of the
spinal cord. A very simple experiment of Danini has
destroyed this hypothesis. In a cocainised animal in a con¬
vulsive attack, to cut the cord will stop the convulsions.
The starting point of these epileptiform attacks is not then
in the cord, but in the part of the axis above the section,
that is to say, in the superior center. Richet thinks that
they are due to an excitation of the motor zone of the
•encephalon.

Certain substances may modify these convulsions.
Skinner has shown that atropine arrests them, chloral has a
like effect, as also chloroform. Morphine, on the contrary, is
a synergic of cocaine as far as convulsions are concerned.

Vol. XVIII.—35

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214 Use of Cocaine and Accidents Resulting from it.

Pradal noticed that a dose of cocaine incapable of
causing convulsions produced immediately an epileptiform
crisis if an equal dose of morphine was added. Neverthe¬
less, habitues of morphine can take a great quantity of
cocaine without danger. Chouppe explains this by saying
that the cerebral cells have their excitability so depressed
by the continued action of the former alkaloid that they can
no more respond to the action of the latter.

Finally, temperature has a manifest influence on the con¬
vulsions.

Grasset and Jeannel have denied this influence, but
Richet and Langlois have proved that cocaine does not differ
from other convulsive poisons. Numerous experiments have
permitted them to establish this fact “ that the convulsive
dose of cocaine varies with the organic temperature of the
animal. It is weaker when the temperature is raised, and
the reverse.” These experimenters believe that a chemical
combination takes plate between the living cell and the
poisonous substance. This chemical combination, the de¬
termining cause of convulsion, takes place only at a certain
temperature and is more or less complete according to the
temperature.

From this it seems easy to explain the absence of con¬
vulsions in cold-blooded animals. A priori, , according to
Richet and Langlois , we might suppose that the temperature
is too low to permit of convulsive phenomena; but frogs
heated to 30° do not exhibit convulsions; and, on the other
hand, dogs cooled to 28° have very slight convulsions, it is
true, but still characteristic ones.

Consequently, temperature can explain but one part of
the phenomena; another factor must intervene. Richet
believes in the preponderance of the cerebral system, which,
more or les^s developed, becomes impregnated with a greater
or smaller quantity of toxic substance and reacts in propor¬
tion. In one word, there is a direct relation between the
convulsive dose and the cerebral mass.

A few experiments made with the advice and under the

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Use of Cocaine and Accidents Resulting front it. 215

direction of M. Richet have enabled us to establish this
relation.

In our researches we have found that cocaine does not
act convulsively on cold-blooded animals. However, Robert
obtained convulsions with frogs. Richet in his numerous
experiments encountered nothing of this nature. I have
myself injected very variable doses into frogs ; a number of
them died, but I had not a single convulsion. The only
explanation I can offer is that German cocaine is not as pure
as the French, although chemists, wrongly, decry the purity
of the latter. In fact an absolutely pure product introduced
into the subcutaneous tissue of the frog will never give rise
to convulsive movements.

The same result occurred with all the other cold-blooded
animals operated on.

Very different are the warm-blooded ones: with them
convulsions are the rule, a moderate dose will produce them.
This dose varies with the size of the animal. To get results
that can be compared we have chosen an arbitrary point, an
invariable unity. We have used as a standard the kilo
weight of the animals. Consequently, when we inject
S w., 15 centigr. of active substance this figure independ¬
ent of the total weight of the subject will always be sub¬
ordinate to the unity chosen by us.

In the course of our experiments, one fact has struck us.
With two animals of the same kind, but of different weight,
the one weighing the least was always more sensible to the
action of the drug; although the dose was proportionately
the same.

The reason, we believe, is that the relation between the
total weight of the body and the weight of the brain is to
the advantage of the smaller subject. This relation is very
important; and this importance we shall show by the com¬
parative study of doses of cocaine necessary to produce con¬
vulsions according to the kind of animals. Here are the
results found in standard writers combined with our own
experiments. We give a r£sum£ of them in the form of a
table.

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216 Use of Cocaine and Accidents Resulting from it.

Cobaye: Injected into the cellular tissue or peritoneum.

Dose of Cocaine.

Compain, Paris *86,

0.02

slight excitation.

Personal observation,

0.03

excitation.

0.06

lively excitation.

0.07

convulsions, recovery.

0.08

convulsions, death.

0.08

u a

Laborde,

0.08

u a

Convulsive dose y 0.07

Rabbit: Injection of Peritoneum.

Personal observations,

Dose,

0.05
o.io
0.12
o.i5
0.15
0.18
0.18
0.20
0.20
0.20
0.22

Convulsive dose, o. 18

If we compare these two results we see that the rabbit is
much more refractory to cocaine. It is true that the other
possesses a more considerable cerebral mass. This is per¬
fectly in accordance with our law.

If we take as unity the kilo weight of the animal the
rabbit will have a brain of 4 gr. and the other one of 7. (It
is, of course, understood that these figures represent only an
average.)

Let us continue our study with birds. Here is the result
of our experiments on pigeons :

Pigeons: Injected into the large pectoral muscle.

Personal observations.

Dose of Cocaine.

0.02 excitation.

*0.05 loss of equilibrium.

0.06 convulsions, recovery.

0.07 “ death.

0.08

nothing.

excitation.

lively excitation,
convulsions, recovery,
lively excitation.

convulsions, recovery.
<< . «

“ death.

ft ft

«( it

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Use of Cocaine and Accidents Resulting from it. 217

Thus the convulsive dose for pigeons is 0.06. Our figures,
and those of the authorities, permit us to fix the average
weight of the brain in its relation to the weight of the
animals at 8 gr.

For dogs, Richet and Langlois have proved that the
convulsive dose is 0.02. We have contented ourselves with
finding the weight of the brain, and, bringing it down to
our unity, we have obtained a weight of 9 grammes.

Now, if we group the result^ obtained we shall see that
hypothesis of M. Richet is verified. The following table is
significant in this respect:

Weight of the brain brought down to kilo of the
animal.

Rabbit,

Convulsive dose.
0.18

Cobaye,

0.07

Pigeon,

0.06

Dog,

0.02

Ape,

0.012

On examining this table we find that the dose necessary to
produce convulsions is smaller in proportion as the brain is
larger.

This given, can we not determine approximately the dose
in man ?

According to Cuvier the average relation between the cere¬
bral mass of man and the total weight of the body is 1/28.
This gives the figure 35 if we bring this proportion to our
standard. Now, by consulting the above table we see that
the difference in the cerebral mass is less between the dog
and the ape than between the ape and the man; conse¬
quently the difference in the convulsive dose between the
ape and the man must be greater than between the ape and
the dog. It will then be less than 0.005. We shall then
fix it, in a somewhat arbitrary way, at 0.002 or 0.003.

When we employ a quantity of cocainj superior to that
which is capable of provoking epileptiform movements, the
animal is often killed. We need only refer to our table to

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218 Use of Cocaine and Accidents Resulting from it

see that the mortal dose follows the convulsive dose. The
same law.governs the evolution of these two phenomena;
and to kill an animal a less quantity of cocaine is necessary
in proportion as the brain is more developed.

The proof of this has been given in our experiments on
warm-blooded animals. We have been pleased to see that
the results obtained by ourselves on cold-blooded animals
confirmed the law of Richet, Thus the frog and the
tench, whose cerebral mass brought to our standard is
practically the same, have nearly the same mortal dose,
0.08 to o. io cent. On the other hand, the tortoise, whose
cerebral mass is less, is killed by 0.20 of cocaine.

In the course of our experiments we at one time thought
our law at fault. Great was our surprise to see that a dose
superior to the mortal dose did not kill a rabbit. Richet, to
whom we submitted this result, told us that he had observed
the same result with strychnine. It is the same with chlo¬
roform. We know that this anaesthetic often produces toxic
phenomena, characterized by vomiting, and that the best
way to arrest the vomiting is to continue to give chloroform.
All these substances are their own antidotes.

We shall no longer follow our physiological study of ani¬
mals. What we have learned will enable us to understand
the action of cocaine on man, and to take up afterwards the
critical study of the poisonings which have been made public
up to this day.

Action of Cocaine on Man,

Cocaine produces on man local effects identical to those
we have obtained on animals. The mechanism of the anal¬
gesia is absolutely the same. A local chemical action
always takes place which suspends the physiological functions
of the sensory cells.

The general effects are equally easy to understand. We
must notice, however, that they are exceedingly variable in
their evolution. To-day we may obtain one phenomenon;
to-morrow, one directly opposite. It appears that cocaine,
in its general action, is not to be compared with itself.

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Use of Cocaine and Accidents Resulting from it. 219

Thus, poisoning by this substance may present itself under
a thousand different forms.

In a general way, however, the intoxication manifests
itself by an extreme paleness of face, acceleration of the
heart-beats, frequent and superficial respiration, precordial
anguish, incomplete loss of consciousness, with a feeling of
the end being near; in one word, collapse, bordering on
coma.

Many of these phenomena may be observed on animals
when we do not exceed what we have termed the physiolog¬
ical dose. Hence, at first sight, a similarity in the action,
and this similarity continues when we employ a stronger
dose of cocaine, i. e. y when we reach the convulsive dose.
Then, as in the animal, we obtain, almost without premoni-
tary symptoms, jerks which become, or which are closely allied
to, convulsive movements.

This convulsive dose cannot be determined in an abso¬
lutely precise manner. We have fixed it (see above) at
0.002 or 0.003 t0 the kilo, which gives for an adult the figure
of 0.20; and, in fact, the published observations, on the whole,
seem to prove that this quantity, subcutaneously injected, is
likely to produce convulsive movements.

If now we take, one by one, these phenomena, we shall
see that all may be explained by the action of cocaine on the
nervous system, and especially by the excitation of the cere-
bro-spinal axis, and this excitation, varying with the dose of
the alkaloid, will give rise to phenomena equally variable in
their evolution, u e., more or less grave.

In the lighter form of intoxication the spinal cord will be
the first and often the only part attacked. Hence the pale¬
ness of the face and ligaments; for in the spinal cord are
principally found the origins of the grand sympathetic, and
we know, from the works of Dastre, that the phenomena of
the circulation are under the influence of the sympathetic
system. We can thus conceive that the excitation of the
spinal cord, due to cocaine, manifests itself, thanks to the
vaso-constrictor fibres, by a notable diminution in the caliber

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220 Use of Cocaine and Accidents Resulting from it,

of the vessels. In fact, the paleness of the teguments is
sometimes extreme.

We understand that under the same influence the circu¬
lation of the brain is modified. Schilling has given a direct
proof of this; in a case of poisoning he examined the eye
with an ophthalmoscope, and found the vessels of the retina
to be hardly visible.

The fact of cerebral anemia is to be remembered, for
there, we believe, is the true cause of certain accidents
which will not fail to break forth if a circumstance, insignifi¬
cant in itself, should favor their explosion. Should the sub¬
ject operated on remain standing; should he be in a state of
profound anemia, or should he be under the influence of an
emotional state whose effect is to lessen the circulation of
the brain, anemiated already by cocaine, we may easily com¬
prehend that we shall find ourselves in the neigborhood of
accidents of vertigo, of tendency to syncope, and even to
syncope itself.

These symptoms, due to a simple cerebral anemia, are
more scaring than dangerous. It will often suffice to make
the patient inhale two or three drops of nitrite of amyl to
bring batk to its normal state the cerebral circulation, and
to cause, at the same time, the phenomena of syncope to
disappear.

It is also to the predominant influence of cocaine on the
medullary axis that are due the trouble of the circulation.
For the excitation of the cervico-dorsal marrow, in which the
sympathetic takes its cardiac fibres, produces a precipitation
of the heart-beats, which raises them to 150 and 160 a min¬
ute. We understand that the blood pressure rises in the
first moments to lower soon after, for the heart-beats, although
numerous, are very weak, losing in force what they gain in
speed. (Marey’s law.)

This excitation of the grand sympathetic may also ex¬
plain many of the phenomena. Under its influence all the
organs with unstriated muscles may contract; and this
action will manifest itself particularly in the pupil, which

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Use of Cocaine and Accidents Resulting from it . 221

will dilate ; in the stomach, whose contractions will often be
increased to the point of producing vomiting; in the intes¬
tine, whose peristalsis may produce purging.

At other times the medullary phenomena will pass un¬
noticed, or even will not exist. The effects of the cocaine
will be localized in the medulla. We shall then see the res¬
piration increase in frequency, thanks to the direct excitation
of the origins of the pneumogastric. At first the frequency
of the diaphragmatic contraction becomes extreme, the
movements are hurried, weak, superficial, then slow, by
degrees, through nervous exhaustion.

If, on the other hand, the cocaine acts on the encephalon,
we see a series of psychical phenomena break forth. The pa¬
tient may have sudden attacks of tenderness; then, without
transition, an access of fury. Sometimes the intellectual
faculties will be excited to the highest degree; he will sud¬
denly remember facts which occurred 20 or 30 years ago,
and which he had entirely forgotten.

Lastly, if the dose is too strong, we shall see the gravest
symptoms, — convulsions. The movements, at first tonic
and then clonic, become more violent as the fatal end is
approached. During the convulsive period we see the face
become cyanotic, the respiration embarrassed, the heart¬
beats less and less perceptible, and the patient dies. How¬
ever, all who exhibit convulsions are far from succumbing.
Their number is even very limited, as we shall see. But in
the cases made public death has always been preceded by
convulsions; and if we remark that warm-blooded animals give
us precisely similar results, we may conclude, not without a
show of reason, that these two phenomena, convulsions and
death, are intimately allied. As the convulsions are due to
an excitation, by the cocaine, of the higher nervous centers,
we must believe that death is the result of a toxic action on
these centers.

A last problem merits solution. Why does cocaine offer
such varying results with different individuals ? Why does
it localize its action, sometimes in one part of the cerebro-
Vol. XVIII.—36

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222 Use of Cocaine and Accidents Resulting from it.

spinal axis and sometimes in another ? The size of the dose
certainly influences the evolution of these phenomena. Per¬
haps we must take into consideration idiosyncracies, indi¬
vidual susceptibilities. This is a point we cannot decide.
We must content ourselves with indicating it.

(i Continued in October Number .)

NEW TREATMENT FOR CONSUMPTION.

Dr. Paquin of St. Louis has been most successfully ex¬
perimenting with anti-Tubercle Serum in the treatment of
consumption. He introduces into healthy horses tubercle
toxines, and from this produces a serum which is anti-tuber¬
cle. This has been found of great value in arresting, and in
some instances curing cases of tuberculosis. The theory
is that an anti-tubercle toxines are formed which arrest the
growth of the tubercle germ, and in certain cases stops
it altogether. This in practical experience proves to be
true. The use of this serum is increasing and every case
where it is used proves its great value. We urge our read¬
ers to write Dr. Paquin for some particulars of this new dis¬
covery, at St. Louis, Mo.

Inebriate asylums may not be the sum of perfection, and
doubtless some of them are controlled by quacks, the class
that owe their lives to the gallows, and ought to pay the bill
at once, but, when rightly managed, we believe these insti¬
tutions are a decided benefit. They are conducted on the
theory that drunkenness is a disease and curable, and we
believe this doctrine will be universal in the near future.
So far building up and deprivation of alcohol are the princi¬
pal remedies in these asylums, but they are, strictly speak¬
ing, psychical and natural remedies. In the application of
such things as these new and more valuable agents may be
discovered. These and similar institutions are schools for
the study of alcoholism and we recognize them as important
auxiliaries in temperance work.— Dr. Flint .

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Alcoholic Inebriety.

223

ALCOHOLIC INEBRIETY.

By C. Spencer Kinney, M.D.,

Assistant Physician New York Insane Asylum , Middletown , N. Y.

To those who delight in the employment of statistics to
emphasize the importance of the points under consideration
and prove the truth of their deductions, the study of alco¬
holic inebriety is not very satisfactory.

The statistics are too confusing. They are modified by
ignorance and indifference; they are distorted by prejudice
and cunning, and suppressed by the pride and conceit of
those whose duty it is to give information on the reception
of the patient for medical treatment.

It appears about impossible to view the alcoholic inebriate
from anything but a sentimental standpoint. Some reform¬
er whose philanthropic eyes have never seen the sun except
when at the zenith, starts the story that eighty per cent, of
crime and insanity has its origin in the use of distilled
liquor, and every printing-press in the country is at once
engaged to educate the masses on this interesting point.

That intemperance in the use of alcoholic liquors entails
misery to the living and the unborn, no one can deny. As
no two human beings are constructed on precisely the same
lines, we cannot expect that they will endure the same strain
with equal degrees of resistance. When a man is suddenly
subjected to any great physical or mental depression he
must thank his heredity for the consequent result; whether
he acts on the impulse of the moment and blows out his
brains, or drowns his grief in the fabled oblivion found from
drink, or whether he bends and not breaks, and quietly re¬
sumes his proper relationship in life.

An inherited predisposition that is shown by a peculiar

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224

Alcoholic Inebriety.

neurotic temperament, coupled with unfortunate early com¬
panionship, leads many into the well-worn path trod by the
alcoholic inebriate.

Emotional overstrains, like worry and grief, may lead
some to inebriety; while physical disease, or injury to the
head, may induce others to fall.

That eminent English authority on inebriety, Dr. Nor¬
man Kerr, claims that eighty-seven per cent, of his cases
have been of a nervous temperament. I think that this is
not far from the proportion that we find in the United
States.

Regarding the nativity of cases of alcoholic inebriety,
we find that they are usually in the following order of fre¬
quency :

(1) United States.

(2) Ireland.

(3) England.

(4) Germany.

The proportion varies, of course, according to the nation¬
ality of the district supplying the patients.

The ingenuity of many writers has developed singular
facts from the causes leading to alcoholic inebriety. Perhaps
some of these simply illustrate the meeting of the extremes
in nearly all conditions of life.

Alcoholic inebriety claims most of its wrecks from the
believers in the Christian religion, Protestant as well as Ro¬
manist, educated as well as unlearned. The Jewish race in
England as well as in the United States, is singularly ex¬
empt from the vices of drink, while the followers of Buddha
and Mohammed put us to shame 'by their immunity from
this induced disease.

Dr. Kerr, in speaking of this condition, says: “As a
whole, Anglo-Saxons seem to be more prone to this disease
than any other race; but the Russians, the Swedes, the Bel¬
gians, the Germans, the Swiss, the French, and the Austrians
seem to be steadily coming up to the English and the Amer¬
icans. In this statement I am not referring to acts of

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Alcoholic Inebriety .

225

drunkenness, but to the overpowering impulse to intoxica¬
tion, the disease of inebriety or narcomania. It is interesting
to note that as Jews carry their sobriety into every country
(some parts of Russia excepted), so do the Anglo-Saxons
carry their insobriety all over the world. We British are the
finest colonist extant, but to our shame be it recorded, our
triumphant march over the inhabitable globe has been
marked by a disgraceful and damning trail of alcoholic
drunkenness, destruction, and death. Our demoralization
and decimation of native races by the drin king habits which
we have taught them, are a hideous blot on the escutcheon
of our fame, a reproach to us as a people, a dishonor to us as
a civilized nation.’' (Page 132.)

Alcoholic inebriety is a constitutional disease of the
higher nervous system, caused by continued indulgence in
alcoholic liquors.

At different vantage-grounds of observation, an alcoholic
inebriate presents a view of diverse proportions. To the
moralist, a self-constituted and self-perpetuating sinner
stands out silhouetted against the light of his “ might have
beens.” According to the moralist all that is required is a
change of habit — a dropping of old associations and meth¬
ods of living; not alone a change of heart, but a complete
revolution of the individual’s mental and moral life. In
theory these views are good, and cover the case with nebu¬
lous possibilities. To be sure, these views are entertained to
a greater or less degree by all who have considered this sub¬
ject. They represent themselves boldly when we state
causes, and they insist on recognition in the management
and treatment of the disease.

To the judicial mind the alcoholic inebriate represents
vice. He is a self-seeking despoiler of his own prospects,
and of his family’s happiness, and stands in need of the law’s
disciplinary, “Ten dollars, or ten days.”

To the physician, who watches the changes taking place
in the one who is gradually yielding to habitual inebriety,
there is but one conclusion to be satisfactorily reached when

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Alcoholic Inebriety.

viewed in the light of cause and effect, and that is — that it
is a disease. As proof, he may state his post-mortem find¬
ings in the congested stomach, the nutmeg liver, the degen¬
erated kidneys, the fatty, flabby, and weak heart and atro¬
phied brain, shrunken membranes, hypertrophied neuroglia,
atheromatous and tortuous vessels, with shrunken and dis¬
torted brain-cells, as shown by microscopic examination.

The action of alcohol on nervous tissue is able and does
produce as great degenerative change in the physical and
moral strength of the drinker, and results in as much of a
disease as is found in terminal dementia or chronic dys¬
pepsia.

If the physician should be in doubt whether the disease
has progressed far enough to be called insanity, let him stand
the inebriate up alongside of this definition of insanity, and
see if it fits: “ Insanity is the prolonged departure from
the state of feeling and methods of thinking usual to the in¬
dividual when in health, as a result of disease of the brain.”
Through the possession of a neurotic taint there are some
predisposed to the drink habit, with whom bad company and
bad advice are in the train of first steps, and an occasional
indulgence degenerates into a habit. It does not stop there,
but goes beyond that stage, and, taking deeper pathological
hold, becomes a disease over which the patient has only a
limited control, owing to the toxical enfeeblement of his
mental faculties.

The full and free public consideration which this subject
has had through the newspaper and magazine press during
the past five years has been productive of benefit in edu¬
cating the masses to a more intelligent comprehension of
this disease.

What the alcoholic inebriate needs is proper medical
treatment, and until he has had this we cannot feel at all
sure what practical use to himself or to society it is possible
to make of him. When a man's system becomes saturated
with liquor from continued drinking, he is in a peculiar
physical and mental condition. Physically, he offers to labor

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and to disease less than his healthy degree of resistance;
for he tires with the one and succumbs easily to the other.
Mentally, his condition is not only peculiar, but lamentable.
From the capable, attentive, pleasant, generous, yet positive
man of business, endowed with clear ideas of his social obli¬
gations, you see, traduced by drink, through various degrees
of transformation, the incapable, inattentive, irritable, yet
vascillating spendthrift, whose ideas are indefinite, and who
often becomes possessed of no more originality than an echo.
His moral sense becomes obtuse, the corners knocked off to
such a degree that his conscience is seldom pricked, and
there is scarcely a day in which he does not attribute blame
to others for a condition in which he has industriously
labored to place himself. This state leads to thoughts of
suspicion of those about him and depression of spirit, until
judgment is seriously impaired. All these symptoms and
more exist, not when the individual is drunk, but when he is
free from the immediate effects of drink. There is a change
in his normal mental condition, and while he may not be
considered insane by those who seek for delusions, yet his
mental strength is enfeebled and he may be properly called
an alcoholic dement. There remains in him no apparent
mental elasticity. This condition is as others see him, not
as he views it; and to others who know what his symptoms
denote, they point to disease. He is willing to admit that
his habit is an unfortunate one, but claims he need go no
further; and if he is recovering from a more than usually
free indulgence, may promise to stop, may give his word as
a man that he will drink no more, and may sign a pledge
with such forms of solemnity as seem most fitting to himself
or friends ; but the instances are few when these vows are
not traced in sand, and the first returning tide of desire finds
the resolve effaced. His reason for relapsing would seem
nonsensical, were we to consider his situation a result of
habit, and not that of an enfeebling mental disease. Two
illustrations will suffice : After several days of drunkenness
a gentleman who was a man of long business experience and

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Alcoholic Inebriety .

superior education, was pressed for a reason for breaking a
long-continued period of sobriety, at last reluctantly ad¬
mitted that it was owing to having received a letter from his
mother, whom he dearly loved. Another of the same grade
of intelligence said it was owing to a desire to see his
mother. He began drinking when he first felt this desire,
and traveled to the city where his mother lived, avoided the
house, and finished drinking in Boston — over two hundred
miles away from home. Neither perceived the foolishness
of his excuse, but clung to it as if it were wholly sufficient
for his conduct. Coupled with this obtuseness of judgment
is a conceit of their mental and moral strength, to which
they look for future freedom from the relapses that have been
in the past steadily working to wreck their lives. This ten¬
dency is shown after a few days of treatment, when the pa¬
tient imagines he has the whisky out of him, recalls the
possibilities of the past, with the degrading necessity for
present treatment, and looks forward to the future and its
kaleidoscopic possibilities, with no apparent thought that his
downfalls are ever to be repeated, and that his pathogno¬
monic story has been told by travelers on his route from all
time.

It is with pleasure that I quote Dr. Isaac Ray regarding
the state of mind held by the patient: “The restoration of
the bodily* condition to something like its customary strength
and firmness, with all the pleasing sensations which follow
such a change, excite no distrust of their power to resist
temptation. On the contrary they are always hopeful, con¬
fident, sanguine, and impatient of delay. They say they feel
perfectly well, have not the slightest desire for drink, and
therefore their further seclusion would be not only unneces¬
sary, but prejudicial to their mental and bodily health. The
amazing confidence such persons invariably express in their
future security is one of the curious traits of this condition.
A great many have come under my observation, but I have
never known one, not even of those who had repeatedly
fallen and had most deplored their infirmity, to express any

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229

apprehension of falling again. On the contrary, from the
moment when they begin to resume their proper conscious¬
ness until they leave the hospital, the burden of their story
is that they are safe forever after; that not the slightest
danger exists of their again disregarding the terrible lesson
of experience. Instead of returning into the world with fear
and trembling, as one would naturally expect to see them,
and seizing upon any excuse for postponing the day of trial,
they go out eager and jubilant, as if bound on a festive
excursion.

“ Thus beguiled by a morbid confidence in themselves,
they determine to resume their liberty in spite of entreaty
and argument, and the institution has no power to prevent
it. Neither the hospital for the insane nor any asylum for
inebriates can hold persons in confinement against their
consent, for any other cause than insanity ; and though our
account of this class of persons does not indicate in them a
very healthy condition of mind, yet inasmuch as they are ap¬
parently rational after the first day or two, both in conduct
and conversation, they cannot be called insane in the ordi¬
nary acceptation of the term. While in the paroxysm, or
suffering under its immediate effects, they may very properly
be called insane, and so long they may, unquestionably, be
deprived of their liberty for the purposes of custody or cure.
But when this condition shall have passed away, forcible de¬
tention in any institution, whatever it may be called, would
be clearly a violation of constitutional rights, and would not
be sanctioned by the legal tribunals.

“A notion prevails, I am sure, that the inebriate asylum'
is to be unprovided with bolts, bars, and guards, and no
means of detention allowed more forcible than the offices of
kindness, good will, and love. Respecting this notion it
need only be said that it indicates but a schoolboy's knowl¬
edge of human nature, and a still deeper ignorance of that
special phase of it which results from long-continued irre¬
sistible inebriety."

The inebriate has no reason to complain that efforts have
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Alcoholic Inebriety .

not been made from time to time to bring about a reform in
his style of living. Probably no treatment for drunkenness
has ever been recommended that has not been of some ben¬
efit to some one. He has been prayed with and sworn at;
he has been treated with loving tenderness, and he has been
abused; he has been thrown on the support of his word as a
man, and he has bowed his head to the decrees from the
bench; he has taken long voyages on water and land, and
he has been kept at home; he has been kept from liquors
by trusty nurses and relatives, and he has been fed with
liquor in every manner that a cunning ingenuity could sug¬
gest. What to do with him has puzzled many. When we
consider that he is suffering from a disease, we are on the
threshold of learning what can be done for him. About
everything that enters into and is a part of him in life and
associations becomes a matter of interest when treatment is
contemplated.

His ancestry, early training, habits, moral and physical
caliber, must be considered in order to determine what kind
of material you have on which to begin.

A man who possesses a weak will, but little moral sense
of responsibility, and a love of low associates can be sobered
up; but the length of time he will remain sober depends
upon time, place, and circumstances. The chances are that
no treatment known will be of permanent benefit to this
class of patients. From sobriety to drunkenness they re¬
lapse with disheartening regularity, becoming more enfeebled
mentally and physically, until they finally represent the drift¬
wood of a community. If the individual has become de¬
mented through the effects of long-continued liquor drinking
it is useless to expect that his mental integrity will be
wholly restored, only that portion of the brain that is unin¬
jured by alcohol is going to act in a fairly healthy condition
after the most satisfactory of treatments.

Every community has a number of men and some women
who are rapidly becoming nothing more or less than shiftless,
habitual drunkards. They are useless to themselves and to

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231

everybody else, and it is simply a question of time before
they become public charges. If they do not become so
themselves, their children stand a good chance of being
wards of the state in one capacity or another, and this should
not be forgotten.

These points are too often overlooked when patients are
completing a. course of drug treatment for inebriety. Some
expect a complete change to occur in the character of the
individual — a change making it impossible ever to drink
liquor again. Now this is nonsense, born of ignorance of
the subject. No treatment is going to benefit permanently
one who has no wish to stop drinking, and who prefers to
associate with those who do drink. An exasperating condi¬
tion of affairs awaits the physician who treats these patients.
He cannot judge, to begin with, just what the outcome of
the treatment may be. The case that appears favorable in
the beginning may relapse quickly, while the one surrounded
by doubt may make a good recovery and return to useful¬
ness after years of spasmodic effort to keep sober have made
his friends weary and disgusted. This simply illustrates that
the effects of liquor may conceal more will-power, self-con¬
trol, and judgment than we may be aware of. In favorable
cases you may expect one of three results — an improvement,
a reformation, or, in a number of instances, nothing more
or less than a regeneration.

I believe that it is safe to say that about ten per cent, of
the patients who are now under treatment in our state hos¬
pitals have become insane by the use of distilled liquor.
Many of these will go out recovered, and some will never
relapse. The majority is likely to break down if circum¬
stances are moderately favorable. Uncomplicated cases of
alcoholic inebriety that have reached the stage of insanity
will not number in this population of our hospitals more
than two (2) per cent, of this number.

The importance of intelligent medical treatment cannot
be too strongly urged, and the less they associate with their
kind during this time of treatment, the better is their chance

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Alcoholic Inebriety .

of recovery. Otherwise they while away their time during
treatment by recounting to each other their past experiences,
with a certain amount of fool pride that is little calculated
to establish a sound moral tone, or to allow them to use
what self-control has not been destroyed by reckless in¬
dulgence.

The instability and unreasonableness of the recovering
inebriate is similar to that of most of the insane at the same
stage. In the inebriate it means, however, a returning
craving for drink. When the period is reached in which the
immediate effects of liquor have passed away and the mind
has cleared up, the necessity of at once attending to business
becomes the one serious wish of his life. It is at this point
in his treatment that the foundation is frequently laid for
relapse from the liberty allowed him by his medical attendant.
In some instances the doctor is led to believe that ruin of the
mind, person, and estate, with a habeas corpus attached, is
going to be the result of prolonged custody.

A number of years ago Dr. Portugaloff, a celebrated
Russian physician, used with marked success a solution of
one grain of strychnine to 200 of water, injecting five drops
every twenty-four hours. So confident was he of the good
results likely to follow that he recommended the establish¬
ment of dispensaries under public control, for the purpose
of giving his treatment to those who needed it. This is be¬
lieved to be a practical and good idea by those who have
given the subject of drug-treatment a thorough trial.

The single remedies .that have been used with success
for the treatment of inebriety are: Nux, belladonna, cin¬
chona, capsicum, macrotin, stramonium, and veratrum viride,
generally in low potencies. It has not been my fortunq to
see the results that have been said to follow the use of high
potencies for the treatment of inebriety, recommended by
the celebrated Dr. Gallavardin.

In addition to medicine regularly administered, hot milk
at frequent intervals, say every two or three hours, as the
condition of the patient demands, should be given, care be-

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Alcoholic Inebriety .

233

ing taken not to overload the stomach, yet giving it some¬
thing to do. Hot milk is not only one of the best of foods,
but it is a tonic in its effects.

It is well to tell the patient the need of time and care,
and the importance of treatment. Tell him it will not per¬
form miracles. No one should be permitted to take treat¬
ment who does not honestly wish to be relieved of the drink
thraldom. The taking of medicine will not render it impos¬
sible for a person ever to take liquor; nor will it restrain him
from associating with those who habitually use liquor. It
will not change the natural disposition of any individual, and
it will be useless to expect such a change. Should a man
be demented by much drinking, there will be nothing certain
about the results of treatment. The chances are against any
help for him. Prolonged treatment will, however, generally
do these things :

It will remove the desire for liquor, rendering it unneces¬
sary for the patient to drink again. It will also improve the
patient's general physical condition, and enable him to en¬
tertain for himself some degree of self-respect.

It will bring out the better qualities of the patient that
have been lying dormant under the influence of this drink
habit. This fact must be seen to be understood. Should
the patient attempt to recultivate the habit of drinking,
there is no earthly reason why he should not do it. Liquor
will have the same effect upon him that it has always had.
Recollect that treatment will enable a man to remain sober
if he so desires, and resolutely cultivates his regained self-
control.

To talk of alcohol as the sole specific cause of inebriety
is a mistake, that reflects on the powers of observation of a
medical man. In almost any circle of life facts to the con¬
trary can be found. Inebriety is a disease of degeneration
involving and depending on many and most complex causes,
and not alone on one drug like alcohol.

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234

Some Remarks on the Morphine Habit .

SOME REMARKS ON THE MORPHINE HABIT.*

By Henry Freeman Walker, M.D., New York.

No one denies the evil effect of the habitual use of
morphia, and all admit, I think, that its employment hypo¬
dermically is peculiarly seducive. I have seen the craving
established, so that it was clearly manifest, after the third
daily repetition of the dose. Opium in no other form, and
by no other method of administration, will so speedily pro¬
duce this untoward result. In a measure this would seem
due to the fact that the relationship of cause to effect is so
clearly established. In a moment one passes from intense
suffering to complete relief; and at the same time experi¬
ences such sensations that he realizes the process ; which, in
other methods of exhibiting the drug, is obscure or wholly
occult.

Opium itself, its tinctures, extracts, or elixirs, may be
given for weeks in oft-repeated dose, and their withholding
may be followed by only slight depression and little craving
for the definite thing. But this cannot be affirmed of the
surest and speediest method of relieving suffering. The
depression is greater and the consequent craving is stronger.

I feel the more strongly with reference to the use of
morphia by the hypodermic needle, because it is a vice for
which the physician is peculiarly responsible. Opium
smoking or eating may be first begun in curiosity, and the
habit continued for the pleasure induced. But the first in
the long series of hypodermic injections is always given by
the physician. Unpleasant consequences, in the way of
nausea or active sickness are no safeguard to the patient,
though these may deceive him. Often I have heard patients

♦Read before the Practitioners* Society of New York, November i, 1895.

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Some Remarks on the Morphine Habit. 235

say, “ There is no fear that I shall take morphine, for its
effects are so unpleasant.” Their very self-confidence
betrays them. They soon discover that the repetition of
the dose affords relief to the unpleasant feeling, and that in
one respect the bane is its own antidote.

Opium taken by the mouth habitually hardly seems to
shorten life, except through the accident of an overdose,
sleepily taken. But the hypodermic needle surely under¬
mines the health, as care in asepsis is always after a time
neglected. But I do not think we compass the evil of the
habit when we view it alone or chiefly in its physical
effects.

To me the greatest evil of the morphine habit is the
perversion of the moral sense. It obliterates in the victim’s
mind the distinction between truth and falsehood, right and
wrong. And here the evil may not be limited to the patient
himself, but this may entail hardship and suffering on all
those about him.

The first effect of opium, in all its forms, is stimulant;
and opium, of all the narcotics, except, perhaps, cannabis
indica, particularly stimulates mental activity. Imagination
replaces observation, and the judgment is in abeyance. We
see this often in cases of illness where the drug has been
exhibited, in which there is no delirium except that induced
by the drug. The patient will describe confidently his
hallucinations as facts, which are as definite as the images
of alcoholic delirium. I have often been told by patients of
the ill-treatment received at the hands of nurse or some
member of the family, which statements I am morally sure
were false. The only explanation is that vivid impressions
on an excited imagination have fixed themselves like facts,
and that the perversion of judgment is due to morphia
alone.

In the description of symptoms, you cannot rely on the
morphine taker’s statement. Anticipated pain is so clear to
the patient’s mind that the future is present, and he declares
himself a sufferer before pain has begun; nor, if in actual

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236 Some Remarks on the Morphine Habit .

pain, can you trust his statement as to the real amount of
present distress. Nor can you trust his statement in regard
to the actual occurrences of his daily history. Imagination
supplies the place of fact, and he dreams in a world of ideas.

And this brings me to the chief point that I wish to
make — a medico-legal one. As you cannot, without other
reason than his own statement, believe the habitual mor¬
phine-taker with regard to himself, nor as a narrator of
events occurring in his daily life, so his testimony on oath is
worthy of discredit in legal matters. Alcohol, when it
fevers the brain, excites the imagination but little, and it
benumbs the memory so that the devotee to alcohol may
make a poor witness by stupid forgetfulness. But the mor¬
phine-taker clearly remembers his so-called facts and
mingles equally the truth and fiction of his narrative. I
would not believe a man addicted to the use of morphine on
oath, were there any reason to doubt his statement. It
might be truthful and it might, equally, be false. I do not
know if this has ever been made a point in taking legal
testimony, but it might, and should be, in a criminal trial.
A man’s character or his life may be sworn away by a
witness rendered incompetent, by the use of morphine, to
discriminate between truth and falsehood.

In any important matter under trial, I believe that the
habitual use of morphine by a witness should be a proper
subject for investigation, and that the character of a witness,
as a witness, is deserving of impeachment if the morphine
habit is found to have made him its slave. It would not be
so if the effect of opium were only to make a man oblivious
or forgetful. Forgetfulness is a venial fault and the stupid
man is merely a poor witness, not needfully a dangerous
one. But the mind of the man who uses the hypodermic
syringe and gives himself morphine is clear, often preterna-
turally clear. It works logically, and granting impressions
to be facts, his conclusions, drawn from given premises,
would be correct. For this reason he is the more danger¬
ous witness. Cross-examination would not shake him; he

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Some Remarks on the Morphine Habit . 237

believes his impressions correct, and his reasoning is logical.
His statement would be overthrown, if at all, by direct
denial.

There is nothing in behavior or general appearance often
to reveal the habit. Alcohol confesses itself, and one is on
guard against the drunkard. As a witness the man who has
been tipsy with drink will be stupid or forgetful, but not
malicious in perverted remembrance. The morphine-taker
will, on the other hand, go about his business, irascible per¬
haps and moody, and able to state a case or conduct an
argument, yet unable to hold the clear distinction between
fact and fiction. If these propositions are true, I believe
that the challenging of the testimony of the user of mor¬
phine should be a thing which the court could sustain.

During the past few months I have been much interested
in the cases of two of my patients, both victims to the mor¬
phine habit and the use of the hypodermic syringe. The
first was a young man of great intelligence, unusual busi¬
ness capacity, and with great business responsibilities. As
an occasion of additional nervous strain, he had a wife to
whom he was devotedly attached, but who was a victim of
ill-health and a complication of nervous troubles. There
could not be a case where the temptation to resort to means
that should produce sleep and forgetfulness could be greater.
The introduction to the use of the syringe had been an
in ercurrent illness of his own, at a time when his wife was
a great sufferer. He felt the need of overcoming the habit,
and determined to do so, and came to me for such help as I
could give him. I found him changed from my former
acquaintance, neat and almost dapper in appearance, to a
man unshaven, almost unwholesome in looks, and with the
air of one who did not get home at all, all night. I urged
him to surrender himself, to close guardianship, give up all
business except that of cure. He quite insisted that, if I
would trust him, he could, with intelligent sympathy, work
out a cure. He knew my faithlessness in the word of a
morphine-user, for it had been repeated to him as a part of a
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238 Some Remarks on the Morphine Habit .

(supposedly) confidential conversation I had had with his
parents in reference to his case. In answer to his inquiry,
I had to admit the fact of having expressed such opinions;
but I added that if he would always give me his full confi¬
dence, his failure as well as his success, I would believe
him. The result was a complete personal history of his
case. He went out of town to be occupied, and sent me
daily and voluminous bulletins of his success or failure. I
allowed him codeia, bromide of potassium, and trional only
as his need should seem to himself extreme. He within
four weeks conquered his habit, and has since lived, not in
full confidence that the desire is gone forever, but with the
determination to resist its most insidious approach.

This case in its bare outline interests me as one of those
exceptional ones where a man of power, mentally, has been
able to dominate his appetite, when he seemed lost. There
is nothing new claimed in the narrative, only the increased
courage derived by the exceptional proof of self-control
makes me look more hopefully on others.

My second case was that of a physician, a friend. He
had been under my care for various illnesses, including last,
a year before, an attack of rheumatic gout which disabled
him for months and was a threat to his life. Before this,
during it, and up to the time when he consulted me, in
March last, he had taken regularly hypodermic injections of
morphine of half-a-grain strength at four o’clock in the
morning, and sometimes at other periods during the day.
He was anxious to be broken of the habit, but dreaded the
suffering of the immediate stopping, or the protracted dis¬
comfort of gradually diminished dosage. He had read
accounts from Paris of the employment of hypnotism in
such cases, and treatment by hypnotic suggestion. He
came to me and begged that I would hypnotize him for this
purpose, saying that he believed I was the only man in New
York who could hypnotize him, and that I certainly was the
only one whom he would allow to do so.

I had always felt a consciousness of certain power in that

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Some Remarks on the Morphine Habit . 239

direction, but had always resisted it, and was wholly without
practical knowledge of the method. His appeal was such a
personal one, however, that I told him that, if I could get
sufficient instruction from my friend, Dr. Starr, I would
attempt the treatment. I had no difficulty. He became
hypnotized the first time in five minutes, at the? subsequent
sittings in three. The first time I used a bright coin, and
in the others the eyes only. From the first three trances I
wakened my friend ; in the two next he was sleeping quietly
as I left his house. He wakened in about half an hour.
During the seances I talked to him, rather iterating and
reiterating the phrase, “ Do not be the slave of the drug,”
than bringing up new thoughts to his mind.

After the first three treatments he took his morphine as
usual, after the next two he did not take it, and had no
craving or sense of loss, and slept quietly and refreshingly
through the night. Since that time he has been practically
well of his habit. I write on June 16th.

In this case I had in treatment the earnest co-operation
of my friend, the patient. He was eager to be free of the
drug, was desirous of being hypnotized, and was sure that it
would be helpful to him. So far it can hardly be considered
an ordinary example of such method of treatment. The
point which most interested me in the case was the cessation
of craving, which ceased suddenly and completely.

My previous notes were written in June. I saw my
friend a few days ago. During the summer past he has had
administered, for pain too great to bear, two or three doses
of morphia, but these have been isolated, and the craving
has not followed its exhibition.

Some Remarks on Dr. Walker’s Paper.

Dr. George L. Peabody, referring to Dr. Walker’s first
case, wished to know whether the patient had had a strong
enough will, on going to the country, to entirely refrain
from morphine.

Dr. Walker replied that he had, but at the beginning he
took a little codeia.

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240 Some Remarks on the Morphine Habit .

Dr. Peabody thought the patient had shown unusual
power of will. Regarding codeia, while it was recommended
as a means of weaning patients from morphine, he believed
that in the form in which it usually came it was equivalent
to morphine, and giving it to these patients was practically
allowing them to taper off from the morphine habit. So far
as he had been able to learn, the weight of evidence was in
favor of rather rapid withdrawal of morphine in the treat¬
ment of those addicted to its use. He would suppose that,
as with alcoholism, gradual withdrawal of the drug would
not be successful.

In the second case, it seemed an unusual train of circum¬
stances had favored the success of the treatment adopted.
The patient was a doctor, he wished to be hypnotized, had
faith in it, and desired to be rid of his habit. Dr. Peabody
doubted the general applicability of hypnotism to the mor¬
phine habit.

Dr. Robert Abbe had been impressed with the fact
emphasized by Dr. Walker — absence of moral force on the
part of the morphine habitu& He thought the loss of will¬
power was equally striking. The few whom he had seen
who wished to break themselves of the habit had followed
the physician’s directions to a certain point, but when it
came to cutting the drug down below a certain amount their
resolution always failed. He had seen two or three very
earnest people try it, but after reaching a relatively small
dose they seemed absolutely unable to go farther. Morphine
habitues suffered from certain sensations or cravings which
they called pain, but which probably were only allied to the
pain sense, and these prevented them from giving the drug
up entirely, although only a small dose might prove sufficient
to allay these sensations. He believed there was a mental
deterioration in the chronic cases which possibly might be
overcome by hypnotism, but he had had no experience with
it. The loss of the moral sense seemed to him a grave
phase of the question. Personally he would not trust all the
statements of morphine habitues.

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Some Remarks on the Morphine Habit. 241

Dr. Hermann M. Biggs asked an opinion, based on two
cases of the morphine habit seen by him. A woman,
fifty-three years of age, had begun to take morphine seven
or eight years ago, for the relief of pelvic pain, and during
the last three or four years had taken the drug continuously.
She was taking eight grains a day when he first saw her.
Within four or five days the amount was reduced 1 considera¬
bly, and it was then that he had occasion to examine the
urine carefully and found that it contained sugar. On
inquiring into her previous history, it proved very suggestive
of glycosuria, from which she had not entirely recovered.
There had been frequent micturition, great irritation, thirst,
etc. He reduced the quantity of morphine from seven or
eight grains to half a grain in the course of a week, and the
sugar in the urine increased considerably, until it was about
four per cent. She had used in the interval some trional
and bromide. She became somnolent, with muttering deli¬
rium, and her condition became so serious that he did not
dare withdraw more morphine, nor did he think it desirable
in view of the glycosuria. Indeed, he gradually increased
the quantity to a grain a day. The patient improved slowly,
and at the end of two weeks was in her normal condition,
taking a grain of morphine a day. The diet was then re¬
stricted, and the glycosuria disappeared, but if a quantity of
starch were eaten the sugar immediately reappeared in the
urine. She had been under observation over two years, the
quantity of morphine taken had remained at one grain a day,
being administered by her daughter or son, and it seemed
she had made no attempt to obtain morphine outside. She
had, however, a craving for stimulants, and it was necessary
to keep these out of her reach. Her health was very fair.

The second patient was a woman, aged about fifty, who
had been addicted to the use of morphine twenty-five years.
She had begun taking the drug occasionally when she was
twenty-five years old for the relief of pain during the men¬
strual period, and for fifteen years had taken it continuously,
in any form she could get it. When, a year before he saw

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242 Some Remarks on the Morphine Habit .

her the opium was cut off, she had been taking ten ounces
of McMunn’s elixir a day. For seven months before he saw
her she had received no opium, but during that time she was
in poor health and had had several attacks of serious illness.
During these attacks she was given alcoholic stimulants, and
later during an attack of hay fever was given cocaine in
spray, and* she immediately contracted the cocaine habit.
She had always had a craving for stimulants, and when Dr.
Biggs first saw her she was taking a large quantity of cocaine
(about twelve grains a day) and as much alcohol as she could
get. On withdrawing the cocaine she passed into a condi¬
tion resembling acute alcoholism—delirium, sleeplessness,
hallucinations, illusions, delusions.

The question arose whether in such a case it was possi¬
ble or desirable to entirely withdraw the opium and attempt
to keep the patient free from narcotics. He supposed it
was a sort of heresy, but he had had the feeling that where
a patient had been so long addicted to the habit, had lost the
power of moral and physical resistance to its influence, and
yet who was in good health, as this patient was, the entire
withdrawal of the drug would require constant surveillance,
and would be followed by enfeeblement of health; and it had
also seemed to him that if any narcotic were allowed, opium
by the mouth, in restricted amount, would prove the least
harmful. He asked for an expression of opinion upon that
point.

Dr. A. Alexander Smith said he felt more hopeful after
hearing the histories of Dr. Walker’s cases than he had felt
before, for he had always doubted the ultimate result in any
case of confirmed opium-taking. Many years ago Dr. Sands
had remarked to him, on observing a morphine habitu6 in
the street, that he did not believe any woman who had
become confirmed in the use of the drug could stop it. Dr.
Smith was then inclined to doubt this statement, but many
years* observation had since convinced him that it was ex¬
ceedingly rare for patients to become entirely cured of this
habit.

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Some Remarks on the Morphine Habit . 243

Dr. A. A. Smith said further, that he had been interested
in the medico-legal aspect of these cases. “Some years ago
I was asked by a friend to go to a neighboring state and
testify in a suit which he had brought against his father-in-
law for keeping his wife and children from him. ‘ What is
the matter with your wife ? * ‘ She is an opium-eater. *

‘ You had better let the case stand, then. If she is an opium-
eater, it seems to me your father-in-law has relieved you of
a very great responsibility/ ‘ I accept that, but I want the
children.’ And then he asked me what view I took with
regard to the reliability of the testimony of any opium-taker,
and I said I thought it was absolutely unreliable. I felt that
an habitual opium-taker was an habitual liar, and when I
took the witness stand and made that statement I was
berated by the opposing counsel, and was asked what I re¬
garded as an habitual opium-taker. The judge seemed very
much interested in the question of the reliability of the
opium-taker, and he turned to me and said : ‘ Are you not

making a very strong statement?’ *1 hope so, for that is
exactly what I intended to make, having been impressed
with the utter unreliability of these people. It is not
because of a vicious purpose, but rather a want of capacity
to tell the truth.’ I should like to ask Dr. Walker what he
considers the smallest quantity of morphine which will make
one a confirmed opium-taker, and render his testimony un¬
reliable ? ” Dr. Walker having replied that he thought it
would depend upon the case, and the effect upon the patient,
Dr. Smith went on to say that his reply upon that occasion
was, two grains at least, and from that amount up. That it
would differ according to the individual and the circum¬
stances. On that statement his testimony was very much
damaged, for in the case in court it was shown that the
woman tolerated large quantities of morphine because of
severe pain.

Dr. F. P. Kinnicutt thought it would be a very impor¬
tant fact if further experience should corroborate Dr. Walk¬
er’s as to the value of hypnotism in the treatment of opium

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244

Some Remarks on the Morphine Habit.

habitues. He had also seen some striking examples of the
perversion of the moral sense in the particular direction of
inability to distinguish between truth and falsehood. The
word of the opium-taker was not to be relied upon; abso¬
lutely not. Regarding the semiology, one point had been
impressed upon his mind many years ago which now was
probably well known to all. He was asked to see a case
with an eminent physician, to determine the cause of an
irregular fever from which the patient seemed to be suffer¬
ing. They were baffled, but later he read of observations
made in Europe on temperature of irregular type observed
in opium-takers, which at once explained the case.

As to treatment: For the past ten years he had em¬
ployed only one method, that of sudden withdrawal of all
opium, not even permitting the patient to use codeia. While
the suffering was great, yet patients who had used both
methods had told him that they preferred sudden withdrawal
to the prolonged suffering of gradual withdrawal. In some
cases the symptoms had appeared alarming, but no untoward
result had ensued. He allowed the patients alcohol in any
form, in any quantity, and also trional, sulphonal, or bromide,
during the treatment. Regarding the ultimate prognosis he
must say that he had not very great hope. Out of a consid¬
erable number of patients treated by him, only one had left
off the drug for a long period. In the one case there had
been freedom for ten years. Of course he was speaking of
the habit of months* and years* duration.

Dr. Beverley Robinson said he agreed in the main with
the previous speakers, but he did not think it wise to sud¬
denly withdraw all opium from one who had long been in the
habit of taking a large quantity. It caused unnecessary dis¬
tress. Nor did he think other stimulants would take its
place satisfactorily. Regarding the question of prescribing
opium, he thought that sometimes it could not be avoided.
That day he had used morphine in a case of headache in a
woman who had consulted many prominent practitioners in
the city without obtaining relief. There were certain men-

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Some Remarks on the Morphine Habit . 245

tal troubles calling for it, and a neurologist had given it
occasionally to one of his patients suffering from melan¬
cholia. Druggists sometimes prescribed the drug, or re¬
peated prescriptions containing it, without instruction from
the doctor. He thought our prescriptions for opium should
be allowed to go only to druggists whom we knew to be too
conscientious to repeat them unless so directed.

Dr. Peabody said, in relation to giving morphine subcu¬
taneously for the relief of headache, that about five years
ago he was asked by a woman to see her husband, a doctor,
who had been in receipt of a very large income from his
practice, but who had suddenly gone abroad for many months
and had only recently returned. The doctor patient quieted
his suspicions by immediately telling him that morphine was
the cause of all his trouble. He asked Dr. Peabody if he re¬
membered who had given him his first dose of morphine,
and stated that it was Dr. Peabody himself, who, seventeen
years before, had administered a hypodermic injection for
the relief of headache. The patient had continued its use
ever since, although there had been intervals.

Dr. Peabody thought we ought not to administer mor¬
phine to people troubled with headache.

Dr. Kinnicutt said he fully agreed with Dr. Peabody.
Women came to us with sick headache, and it did some¬
times seem that morphine was the only drug which would
give them relief, but he was positively of the opinion that it
should not be used in those cases. A migraine was likely to
last a number of years, and if morphine were once used it
would likely be continued.

Dr. Peabody added that his patient died a most misera¬
ble death as a result of a combination of morphine and
cocaine habit. Neurotic people, suffering from chronic neu¬
ralgia, were the very ones to whom morphine should not be
given.

Dr. Robinson said it must be assumed that those physi¬
cians who sometimes gave morphine exercised some precau¬
tion and solicitude. They did not put the drug into the
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246 Some Remarks on the Morphine Habit .

patient’s hands and walk away. There were some cases
which could not be afforded relief in any other way, so that
all one could do was either to administer morphine or walk
out of the room and leave the patients to suffer for hours
with extreme headache. He was not talking to the general
practitioner, but to members of the Practitioners’ Society.

The president, Dr. Andrew H. Smith, could see no reason
why opium should tend any more toward destruction of the
moral sense than alcohol. The only difference was, he
thought, that the person taking alcohol usually found no
necessity for concealing it, while one taking opium always
did so stealthily. At first he lied only with regard to this
habit, but by degrees he became accustomed to prevaricate.
He thought it was wrong to try to corner such patients and
convict them of their habit against their statement, for it
only precipitated the habit of untruthfulness.

Regarding gradual withdrawal of opium, the usual method
was to reduce the quantity by, say, one drop a dose. This
meant a reduction perhaps of one-tenth the first day, one-
ninth the next, one-eighth the next, and so on, the increase
becoming rapid and distressful to the patient. The presi¬
dent had found a better method to consist in filling up the
bottle, if a liquid preparation were taken, by adding water
or alcohol after each use. By this method the reduction
was by a smaller percentage each subsequent dose, but the
amount of opium taken finally became infinitesimal. He
found in practice two classes of opium habitues. The first
class took the drug for the relief of pain or some form of
suffering, and for that reason had not the fortitude to lay it
aside. The second class, much less numerous, could lay it
aside, but continued to take it because of the mental excite¬
ment which it caused. The latter were the most intracta¬
ble. He had known such persons to drop opium for a long
time, until all necessity for it must have been lost, and then,
when the favorable opportunity came, they deliberately re¬
turned to its pleasant sensations.

The president said he had not been able to detect opium

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Some Remarks on the Morphine Habit . • 247

in the urine unless it were taken in considerable quantity.
He asked for the experience of others in that direction. He
supposed all knew that a single dose might send the tem¬
perature up, but he did not know whether, after continued
use of the drug, the system ceased to respond in this way.

As to depriving the patient of the drug suddenly and
•entirely, he recalled the case of a physician, an intelligent
man, who had been under the care of many doctors at differ¬
ent times. At one time his life seemed to be a complete
wreck. Finally it was found that by allowing him a certain
amount of morphine every day it would not incapacitate him,
and he could attend to a large consultation practice. There
was no reason why this moderate amount of morphine, which
was essential to him as his daily food, should be cut off.
He knew one woman who had become a wretched creature
through the use of morphine, mentally, morally, and phys¬
ically. Under some influence she gave up the drug, regained
her health and beauty, and happiness was restored to her
family. After a number of years, within the last year or
two, she had gone back to opium, and was again becoming a
wreck. It was difficult to understand why a person, after
such an experience, and after so long a respite, should fall a
victim to the drug again.

Regarding habitual headaches, they were difficult to
meet at times, and often it seemed cruel to withhold a single
injection of morphine which was capable of giving relief.
He could hardly bring himself to say that it was wrong to
use the drug in such cases when the intervals were long and
the danger of establishing the morphine habit was not so
great. In one case the woman had suffered about once a
month for years, and he was in the habit of giving her relief
with a single hypodermic injection of morphine. Finally,
he induced her to consent to an operation for very slight
strabismus, and from that time the headaches had ceased,
and she had received no more morphine.— Medical Record.

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248

Habitual Drunkards in Austria

HABITUAL DRUNKARDS IN AUSTRIA, AND
THE CURATEL PROCEDURE.

By Professor Schlangenhausen.

Drunkenness, whether in the form of delirium or of
chronic alcoholism, or as the origin of divers mental dis¬
orders, lays claim in Austria — at all events according to
statistics — about as frequently as in other countries, to a
number of victims in about equal proportions amongst the
lower, middle, and upper classes of the population.

Undoubtedly statistics of different provinces show differ¬
ent results ; but the fact remains that, taking all the patients
in the different asylums for the insane, the number of hab¬
itual drunkards varies from ten per cent, to forty per cent,
of the entire patients in each asylum. Thus, for instance,
the asylums for insane persons in Lower Austria are, accord¬
ing to the reports of the Provincial Committee, overcrowded,
owing to the fact that forty per cent, of the patients annu¬
ally admitted are habitual drunkards. The procedure
actually in force affecting habitual drunkards who, owing to
their unconscious condition, or to their state of excitement,
or as the result of crimes committed by them, or of attempts
at suicide — have in some way or another come into collision
with the police, is precisely the same as that which is ap¬
plicable to the rest of the insane patients. Drunkards, as a
rule, are first handed over to the charge of a “ Psychiatrische
Klinik” or to the charge of a hospital for examination and
subsequent observation, and are thence transferred after a
certain interval to a Provincial asylum for the insane. It
is there where, in their case, as in the case of other mental
sufferers, the Curatel Procedure first comes into operation ;
for the law says: “persons who require Curatorship are

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and the Curatel Procedure .

249

those who are incompetent to manage their own affairs, them¬
selves, and to guard their own rights themselves; ” and
these psychologically degenerated drunkards are just the
persons who are the least able to do this. (The manner in
which the Curatel Procedure is carried out has already been
explained by the author of this paper in his Austrian pro¬
cedure re-Curatel.') Drunkards then remain months, even
years, in asylums ; and, in complete accordance with the
views expressed by Dr. Kesteven at the meeting of the
Society for the Study of Inebriety, their detention in such
asylums has proved itself to be in the highest degree con¬
ducive to recovery and in fact has frequently led to that re¬
sult. Intoxication gradually vanishes from the organism,
the power of resistance becomes strengthened, the sufferers
become morally stronger, the manager of the asylum, where
they are confined, feels that he can conscientiously discharge
them, the curatel which has been put in force is annulled,
and the patients enter again into full possession of their
civil rights.

But after a shorter or longer interval spent in the outer
world, owing to the patient associating with former com¬
panions, the power to resist alcohol diminishes; and it
frequently happens that after months, and occasionally after
weeks, the whole procedure — that is to say the reception
into the asylum and the application of the curatel — must
be gone through over again, so that drunkards have been
known to have been placed under curatel and to have had
their curatel annulled from ten to twenty times until finally
their complete psychological degeneracy renders them only
fit to be permanent inmates of an asylum or death puts an
end to these recurring scenes.

Inasmuch as a large number of habitual drunkards are
not brought to the asylums by the police and consequently
do not share the protection afforded by the application of
the curatel, and whereas it is precisely the drunkards in the
asylums who harm the other poor suffering inmates; and
whereas the former enjoy the free treatment now in use in

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250 Habitual Drunkards in Austria

the asylums and are well able to abuse the advantages of
the said free treatment; and whereas the said drunkards
also manage to provide the other patients with alcoholic
liquors supplied within the asylum or smuggled inside the
asylum; and whereas being generally morally depraved
individuals they exercise the worst possible influence upon
all around them ; and whereas finally these said drunkards
cannot always be suitably treated and looked after, the
Austrian government purpose constructing special asylums
for drunkards to be placed under state control and to be
similar to those which, built principally by private individ¬
uals, already exist in Switzerland, in the United States, in
Germany, in Sweden and Norway, and in some of the
English colonies.

Into these asylums persons are received whom the
ordinary measures provided by the legislature have failed to
keep from drink; such persons, in fact, who, by reason of
their shattered and failing constitutions and in consequence
of their ever increasing mental and moral decay and degen¬
eracy, and owing to the danger to others arising from their
irritability and tendency to violence, and finally on account
of the baneful influence which they exercise in all family
and household matters — have made existence in the outer
world impossible for themselves.

Briefly, the above grounds induced the Austrian govern¬
ment to bring forward last year in the XI Session of the
Chamber of Deputies a Bill to authorize the construction of
Public Asylums for drunkards.

In accordance with paragraph 10 of this bill, habitual
drunkards could be brought to one of these public asylums
for inebriates on the order of a judge at the instance of
nearest relatives or of guardians, or on the application of
the manager of an asylum for insane persons, or at the
request of a magistrate based on the written reports of
experts in lunacy; and the final decision respecting the
removal of the patient to such asylum rests with the
Supreme Court. (Paragraph 11.)

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and the Curatel Procedure .

251

In the event of an habitual drunkard possessing prop¬
erty, a curator must be appointed for such a person, the
procedure being the same as that in force in the case of an
insane person. The period of detention is limited by the
bill to two years; and in the event of a relapse on the part
of the drunkard, a further detention may be enforced for a
like period of two years. So much for the procedure at
present contemplated by the Austrian government respect¬
ing the future detention of habitual drunkards in public
asylums specially constructed for them.

In conclusion, attention must be again called to the fact
that up to the present time in Austria habitual drunkards,
in common with other persons suffering from mental dis¬
orders, have for their own welfare and for the welfare of
those around them been confined and treated in asylums for
insane persons; and the application of the curatel has been
found to act beneficially in such cases and to promote the
cure of the patient.

On the summit of Lookout Mountain at Chattanooga,
Tenn., over half a mile above the sea level, is a hotel of
great beauty and comfort for invalids and persons needing
rest. The panoramic scenery, which includes places of great
historic interest, is unsurpassed by any other place in this
country. The hotel, its management, and surroundings are
without question the most pleasing and attractive of any
mountain resort in America.

The second Pan-American congress will be held in
Mexico, November 16th, and continue four days. Dr.
Reed of Cincinnati is ex officio secretary, and a most cordial
invitation is extended to all physicians to attend. The occa¬
sion and place and unusual facilities offered will make it one
of the most attractive journeys of a lifetime. Send to Dr.
A. L. Reed of Cincinnati for particulars.

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252

Abstracts and Reviews.

kr\d f^eview^.

ON THE EXCEPTIONAL EFFECTS OF BROMIDES.

By S. Weir Mitchell, M.D., LL.D., Philadelphia.

The ordinary or excessive use of bromides sometimes
occasions symptoms which are familiar in their milder ex¬
pressions, but which, I am sure, are rarely seen in their
more interesting and aggravated forms; or, if so seen, are
not always suspected to be due to the use of these salts.

In certain people these rare and extreme results are not
due alone to the bromides. The prodromes, or the conse¬
quences, of an epileptic fit may, because of the bromides, be
intensified even in those whose attacks are being lessened in
number. This, I am sure I have seen, and I have several
times had remarked by the nurse, or the patient’s relatives,
that the irritability so often seen before or after a fit was
the worse for bromides.

Menstruation admits of the same comment. The curve
of irritability or melancholy being sometimes higher at this
time in epileptics under free use of bromides.

Trauma affecting the brain, as from fractures or in¬
ternally called lesions, may give us to see excessive displays
of bromic influences * causing bad temper, suicidal or homi¬
cidal tendencies, temporary delusions. Cases of necrotic
changes, from emboli or thrombi, may be thus responsible
for unusual bromic effects ; but it is to be remembered that
of all the mental symptoms evolved by bromides irritability
alone is common, and the rest exceptionally rare.

Most people take the usual doses of bromides without
other ill effects than acne, roughened skin, and excess of
urine, especially if it be the lithia salt which is used.

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Abstracts and Reviews .

253

Dr. Da Costa calls my attention to the fact that, although
ordinarily these salts do not disturb the circulation, they
may do so when certain functional failure of heart-force
exists. He says, “ I have been struck with the fact of the
depressing, and even serious, effects in those who have weak
hearts, and especially the form of cardiac weakness desig¬
nated as chronic cardiac asthenia. The action of the heart
becomes distinctly feebler under the continued, decided use
of bromides, and sweats are apt to break out; all of which
symptoms disappear when their employ is discontinued.”

In a few patients even moderate doses occasion the
paretic symptoms always seen soon or late in such as are
using immoderate amounts of these agents.

One of the earlier physical effects, as Dr. Rudisch, of
New York, has pointed out to me, is a tendency to ptosis;
the lids fall more than is common, the eye space is narrowed.
Next comes increasing paresis of all the limbs, even to
inability to walk, and this feebleness may be so much more
notable on one side as to look like a hemiplegic condition.
As the weakness increases, the spinal muscles are affected,
and, for a time, the spinal curves are altered and to sit erect
is difficult. The pupils are moderately dilated. On the side
of the mind, there is failing memory, difficulty as to fixation
of attention, hebetude, and so, at last, a general condition
like that of some partial imbeciles.

With paresis there may be indifference as to body habits,
or the sphincters may be so relaxed that the feces or urine
cannot be retained. This extreme state of things we rarely
see, but now and then accident or reckless lay use of the
drug in question gives an opportunity of the utmost interest.

I saw, in 1887, a child of 15 years, long subject to Jack¬
sonian epilepsy ending in general convulsions. The father,
an apothecary, determined to suppress the disease by the use
of bromides. “ If,” he said, “ a drachm a day holds the fits in
check, two or more should put an end to them.” On this
theory he increased the doses to 150 grains a day. After
ten days of this treatment I saw the child. She was unable
Vol. XVIII.—40

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254

Abstracts and Reviews .

to stand, and when seated, her head dropped forward, and
she remained, as the mother said, “ all of a heap.” The
eyes were a third open, the pupils large, the sphincters
relaxed, and the saliva flowed from the fallen jaw. As to
her mind, she was quite imbecile, hard to arouse, and
stupidly indifferent. The general convulsions had ceased,
but the lesser fits were quadrupled in number,— a not rare
incident. A few days without bromides restored her to
normal conditions of body and mind, and the state of partial
idiocy was exchanged for normal condition of rather unusual
intelligence.

I saw, many years ago, and at nearly the same time,
in my wards at the Infirmary for Nervous Diseases, two
children, each of whom took daily, owing to a mistake of
the nurse, nearly ioo grains a day of lithium bromide. I
had just introduced this bromide into medicine, and was giv¬
ing it to all the cases to which previously potassium bromide
had been given. These two children were between io and
13 years of age, and were both cases of mild epilepsy. In
a few days both were brought into a condition of extraordi¬
nary feebleness of mind and body. Memory was impaired in
both, so that one forgot the letters of the alphabet, and, of
course, could no longer read ; the other had some curious
confusion as to the time of events,— misdating them. My
visit, she declared to the nurse, was made the day before,
although I had just left her bedside. Her dinner, she said,
had been taken early that day, and yet the tray was still
before her. Her memory of events was, if not sharp, at
least such as to enable her recall all things of recent occur¬
rence, but she never succeeded in relating them correctly to
the time of week or day.

This interesting state of altered memory was naturally of
brief duration, passing away within two days after the
bromides were withdrawn. In both of these cases the
weakness was very great; both could stand, swaying some¬
what, but neither could walk. When this was attempted
they both fell to the left, the left leg being manifestly worse

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Abstracts and Reviews .

255

than the right, as is often the case in drunkards, some of
whom are often more drunk on the left side than on the
right.

There are a few cases in which bromides (sixty grains
daily) occasion at first a mere depression of spirits, as we
say, which, save in rare cases, is not lasting. Now and then
we find people who do not bear any effective dose of bro¬
mides, and who are in a state of moderate melancholia so
long as we give the drug. In a still smaller number the
effect of each dose is felt in a deepening of the sadness.

In exceptional cases this influence may rise to the grade
of danger and occasion suicidal impulses. Of this I saw, a
few years ago, a strange example. A lady, the wife of a
physician, consulted me as to long-continued sciatica. She
had had, four years before, three severe convulsions while
nursing her last child. Ever since she had continued to
take sixty grains daily of mixed bromides, being in constant
dread of another attack. The medicine did not trouble her,
nor was there the least sign of acne. She was, at this time,
about 47 years old, and was becoming slightly irregular as to
the time of menstruation. Within a year she had begun to
be intensely depressed at, before, or a few days after the
menstrual onset. Of late this recurrent melancholy was
such as that for four days at the beginning of the flow she
had suicidal impulses. The mid-interval was, she assured
me, free from this distress of mind. About this time she
reluctantly confessed to the constant use of bromides, which
I induced her to abandon. To her surprise, the next period,
which came two weeks after disuse of the drug, was nearly
free from melancholy, and the next entirely so. These
abrupt endings of any type of melancholy are rare, but still
clinically possible: However this may be, the melancholia
was seen no more for a year. Then, while suffering from
temporary loss of sleep, she was given for three or four days
ninety grains a day of some bromide. It plunged her into
deep melancholy, although she was not at the time menstru¬
ating. The drug was abandoned and the symptom went

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with it. The dose was larger than that which with the
menstrual crisis had before seemed competent to occasion
melancholy.

I have seen other examples of grave melancholy from
bromides in males, as well as in females, and in one notable
case of bromic habit a very intense melancholia with a face
so sombre as not easily to be forgotten.

It is far more common to see irritability of temper occa¬
sioned by bromides. In old epileptics it is laid to the score
of the disease, but that it is not always of this parentage is a
matter worth remembering in extreme cases.

I know of several cases of old epilepsy in which the
families of the sufferers came to understand that the bro¬
mides were the causative factors in giving rise to states of
irritability, abruptness of manner, or peevishness in persons
by nature gentle and amiable. When the outbreaks of
temper were extreme in these cases, it was customary to
stop the bromide for a week, and to take the risks of an
attack for a time at least.

Last year I saw in my clinic service two young epileptics
(both boys) who were what their parents termed “ ugly-
tempered” while using bromides, apt to break things, short
of temper, “ sudden-like,” was the description given of one
them.

This tendency to destructive outbreaks with unrestrained
violence of temper does, in a few people, rise to the danger¬
line.

Ten years ago I was consulted as to an epileptic lad, the
son of a physician, who could not take bromides a week
without becoming homicidal. I disbelieved the account
given me, or rather thought some mistake might have been
readily made in an epileptic as to the cause of these out¬
breaks. I was reluctantly permitted to give forty-five grains
a day of potassium bromide. The experiment came near to
resulting in a tragedy, and I became amply satisfied.

Another case of like nature, also an epileptic, was seen
in a young and sturdy farmer. All use of bromides had to

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be laid aside. If he took them he began within a week to
be both irritable and depressed; later, the melancholy
lessened and the irritability rose to conditions of unre¬
strained anger, often upon the slightest provocation. If the
bromides were still further pushed, this man grew sullen and
dangerously homicidal.

I saw a case much like this a few years ago while acting
as consultant to the City Hospital Insane Wards. The
sufferer was a partial dement from years of epilepsy, but
under bromides became violent and dangerous. No doubt
the asylums could tell us of other and similar cases.

My friend, Dr. Draper, permits me to relate a case within
his experience. A lady in middle life, ill in Paris, was seen
by Charcot and Brown-S£quard on account of some disturb¬
ance of general health and loss of sleep. Very soon she
became excited, and soon after so wildly maniacal as to
give rise to the gravest prognostications. Her friends in
this country heard by cable of her state. Dr. Draper
promptly asked if she were taking bromides. She had been,
but they had been laid aside by Charcot's suggestion. In a
few days she was well. Dr. Draper’s previous experience of
the case enabled him to suggest the cause of this sudden
mania.

Hitherto I have spoken of these unusual effects of bro¬
mides in the healthy, or in those who have no more pro¬
nounced lesions than the ordinary types of epilepsy present.
Occasionally persons who have had emboli, or destructive
necrotic processes about clots, or from thrombosis, or those
who have had traumas show extraordinary susceptibility to
bromic influences of unusual nature.

The worst case of almost sudden bromic toxication I saw

years ago in consultation. A young man had rheumatism,
heart-disease, and multiple emboli, one in the middle cere¬
bral artery on the right side. After a perilous rise of tem¬
perature it fell to ioo° F. for two weeks, with increasing
evidences of destructive irritative changes in the brain. At
this time one drachm of potassium bromide used daily for

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three days resulted in acute mania. It was laid aside, and
only when used anew had I the suspicion that my drug was
to blame. A third experiment satisfied me.

I have seen but of late an intelligent and able engineer,
who was so injured during a railway accident as to become
palsied on the right side and comatose, until relieved by
trephining and the removal of depressed bone and a small
spicula of bone which penetrated the brain about one-fourth
of an inch at the anterior parietal margin.

A skillful operation was followed by swift and entire
recovery. Living at a great altitude, and subject always to
neuralgic headaches, he now began to sleep badly and to
have severe headaches. For this insomnia he took without
orders a bottle or two a day of some proprietary stuff known
as bromoseltzer. The amount thus taken could not have
exceeded eighty grains a day. His very competent physi¬
cian at this time, learning of the habit, told him to give up
the bromoseltzer, and later, under the impression that he
had obeyed orders, prescribed the use at bedtime of a small
dose of chloral with thirty grains of potassium bromide.
Meanwhile, with increasing irritability of temper came
lessened capacity to manage affairs. Then at times he
became violent and threatening and at last even dangerous.
It was thought well that he should live at a lower eleva¬
tion, and with this in view he was sent hither and put under
the care of Dr. John K. Mitchell.

To get a full knowledge of his condition all drugs were
laid aside, and we then learned that despite his physician’s
orders he had continued to take bromides in excess. A
week after he ceased to take them he was freed from all the
distressing symptoms which we and others naturally put to
the credit of the cerebral lesion. He was no longer irritable;
he became, as he was before the accident, amiable and
merry, and has been able to write long letters and to discuss
and decide matters of business. Those who know him best
can see little difference between his present condition and
that with which they have been familiar in past years.

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It should be said that this excitability could be as easily
and more quickly awakened by the smallest amount of alco¬
holic stimulus or any large use of tobacco.

Escheverria was the first, I believe, to call attention to
the fact that bromides are competent to give rise to suicidal
and homicidal impulses.— University Medical Magazine .

ENGLISH EXPERIENCES IN TREATING FE¬
MALE INEBRIATES AT HOME.

The following, as a nurse’s experiences in treating women,
appeared in the Temperance Record:

“ The patient was a girl barely sixteen years of age, the
only child of a man whose name is something to conjure
with in the commercial world.

“I was shown into the library, where the father was
waiting to speak to me.

“ ‘ Cure my child, and be it money or money’s worth,
you have only to ask and you shall have it,’ were his first
words.

“ The girl had been sent home from boarding-school in
disgrace. The principals of the seminary, anxious to retain
their best-paying pupil, had shielded her from time to time.
But when, at length, not content with drinking to the verge
of intoxication herself, she was found to be leading several
of the other pupils in the same direction, there was nothing
for it but the sternest of measures.

“I asked how long the girl had been drinking, and the
father’s face fell. ‘ It is all my fault,’ he acknowledged with
tears in his eyes; ‘from the time she was a little thing —
five or six years old — every time I had a few friends to
dinner, she would pretend to go to sleep so as to get the
nurse out of the room. Then, when the dining-room was
empty, she used to steal down and drink what was left in
the glasses on the table. When I found this out I treated
it as a joke. But as the years went on, the joke developed
into a grim reality, and before she was twelve years of age

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my child was a confirmed drunkard. The doctors tell me
if anyone can do anything, you can. And you will, won't
you?' he concluded.

“ I promised to do my best, and I did all I could.

“ My patient was not violent, but she would lie for hours
on a couch by the window, staring up at the ceiling till I
feared her reason would go, although the doctors assured
me there was no danger of such a calamity. I had been
there about ten days watching her as a cat does a mouse,
when all at once she began to brisk up, a state of all but
coma being replaced by a condition of positive animation —
such, in fact, as occasionally arises from the moderate use
of alcohol. But with the watch that was kept over her I
ridiculed the idea that she could get hold of any intoxicant.
They could not get anything of the kind past me, and dur¬
ing the few hours I was off duty my place was taken by the
girl’s mother, who would have seen her daughter perish at
the stake before she would have given her a drop of alcohol.

11 1 came on duty at five one afternoon to find my patient
not precisely drunk, but pretty far gone in that direction. I
questioned the mother. She answered me that no one save
herself had been in the room since I had left it in the morn¬
ing. I asked my patient. As is usual with dipsomaniacs,
she gave me her most solemn vow she had never touched a
drop of stimulant. It was a mystery, but, like most mys¬
teries, capable of solution, and I had not long to wait for
the eclauxissement.

“ My patient’s couch was drawn across one of the win¬
dows, which, as the weather was mild, was opened for an
hour or two in the afternoon. On the ledge outside the
window there was what appeared to be a flower-pot:

“I had noticed it more than once, and wondered why
the pot was kept in that particular position when it displayed
no signs of vegetation. My charge’s mother having some
calls to make one afternoon, I came on duty at half-past
three instead of five. I was sitting about the middle of the
room, and had just picked up a paper, when my attention

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was attracted by a sound like the trickling of water. My
patient was lying on the couch with her eyes closed as I
darted to the window and looked out.

“ The top of the imitation flower-pot was off, and into
the receptacle there was trickling from a gutta-percha tube
a stream of—whisky! I looked into the grounds for the
propelling power, which I found in the shape of the under¬
gardener, who was skillfully manipulating a garden engine.
This kind of thing had been going on for some time. Had
I not come on duty earlier than usual that afternoon, it
might have gone on indefinitely, as the lady of the house,
though keen of sight, was hard of hearing. The funds for
the whisky had been provided by my patient throwing into
the grounds an occasional article of jewelry, which her ac¬
complice pawned. I cannot say how they finished up with
the under-gardener, but two days later the young lady was
removed to a Home for Inebriates, where she still remains.
How much did the flower-pot hold? Very nearly a quart.
A pretty fair allowance of whisky for a girl not sixteen years
of age, was it not ?

“ There's no doubt but that the taste for drink is hered¬
itary. Sometimes it is the girls who suffer, at others the
male branches succumb — only too frequently both sons and
daughters fall victims. Now and again the disease skips a
generation, only to break out after a lapse of years.

“There is one family I attend with almost clock-work
regularity. It consists of three sons and four daughters.
The sons never touch intoxicants; the daughters drink, and
drink hard. The father is a wealthy man who could give
his daughters good portions. They are handsome and ac¬
complished girls, and yet not an eligible suitor dare come
forward. The one failing of the young ladies is too well
known, and the go-ahead man of the present day is not so
blind as to tie himself for life to a woman who will drink, at
all hours of the day, anything she can lay her hands on.
Strange to say, the father and mother are staunch teetotal¬
ers, but both the mother's parents had been heavy drinkers.

Vol. XVIII.—41

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“Are no steps taken to cut off the supplies of drink?
Most certainly. The allowances of the girls are stopped.
They sold the contents of their wardrobes and pawned their
jewelry, to get money for drink. When these sources of
revenue became exhausted, they went into town, bought
new things on credit, only to sell or pawn the articles within
half an hour of the purchase. Their father closed their ac¬
counts at the shops where they were known. Not to be
beaten, they ran up an account for over £50 at a hotel not
far from their house. This their father paid, naturally much
against his will. Still, his standing in the commercial world
would not permit of his being dunned day by day for a pub¬
lican's bill.

“What do women drink? Anything; and the stronger
it is the better they like it. Spirits of wine will do if they
can't get anything else. Brandy is the first favorite. When
they can afford it, champagne and brandy mixed. They
take little or no water in their spirits, and the amount they
can get through would surprise you. I had one lady patient
who, when she was going about, would dispose of a bottle
of brandy in less than an hour. And to talk to her you
would not think she had touched a drop. That was the
danger signal. It showed the drink was being absorbed
into the system to presently complete its work by mounting
to the brain.

“ The woman who has a craving for alcohol will descend
to any meanness to obtain drink. The husband of one
young married lady I attended cut off her pocket money
and her credit at the same time, save in one quarter — a
livery stable. He did not think she could get any value she
could turn into drink in that quarter. After lunch she used
to dress in the most elaborate fashion, send for a hansom,
and be driven to a certain public-house. She would sit
down in,the bar-parlor, take up a newspaper and pretend to
read. She had not long to wait before one or other of the
customers would ask her to have a drink. The invitation
was always accepted. When the male generosity was ex-

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hausted, or the male purse gave out, she used to step into
her hansom and be driven to another public-house, where a
similar programme would be gone through.

“The credit at the livery stable was stopped. The
young lady went out just the same every afternoon, only on
foot instead of on wheel. Her excuse was that if her hus¬
band did not think fit to trust her with money, she was not
worth trusting at all. So she went on day after day, until
the inevitable result was attained. I was called in to attend;
the best possible medical advice was brought from all
quarters. But the commonest and most fiery of public-
house whisky won the day, and she died in delirium.”

DALRYMPLE HOME, R 1 CKMANSWORTH.

Extracts from a Report of Medical Superintendent,
Dr. Branthwaite, for the year ending
January 31, 1896.

Although actual admissions fall short of the number pub¬
lished in my last report, the house has nevertheless been
practically full throughout the year. This apparent discrep¬
ancy is accounted for by the fact that two patients in the
house at the close of last year still remain under treatment;
and, furthermore, no less than fourteen of the thirty admit¬
ted entered for the full period of twelve months. This, of
course, only left limited accommodation for applicants at
shorter terms.

Twenty patients remain under treatment. Adding this
number to those detailed as discharged, the total of admis¬
sions— four hundred and twenty-seven — is obtained, since
the opening of the home.

When the inebriates acts became law, there were many
who foretold the probability of an entire want of applicants
who would be willing to place themselves under its provisions.
It is interesting, therefore, to note that, (although the way
has always been open for entry under private contract), no

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less than forty-eight per cent, of all admissions have been
“under the act," and of these thirty-five per cent, have
entered for the full possible period of twelve months.

On the question of admission it is greatly to be regretted
that statutory powers demand such a formidable barrier as
signature before two justices. This has proved a great
deterrent to many who would otherwise perfectly willingly
have availed themselves of the provisions of the act.

After an intimate contact and constant association with
patients for nearly twelve years, I am more than ever con¬
vinced that could we but obtain an earlier chance, much
more good would result. As it stands at present, the for¬
bidding obstacles placed around admission under the act are
such as to prevent many from attempting to surmount them
except as a “dernier resort," or until they have lost all hope
or care for the future.

Although many, even under these advanced conditions,
recover absolutely, still the outlook would be brighter and
percentage of good results greater could we but obtain power
over patients earlier in their habits. This result will only
obtain when admission to a retreat has more of a restorative
and less of a judicial aspect.

Just a word on another point. Were it not for the
urgency of the question I should apologize for again refer¬
ring to it, — but year after year the demand forces itself
upon my attention, and as often I am impelled to mention it
to you, — can nothing be done for our destitute male inebri¬
ates and for those of limited means ? There is an enormous
field here for philanthropic enterprise, and much of the
energy and money freely given for external purposes might
be applied in this direction at home. The desire for intoxi¬
cation is as much a diseased condition as any other
monomania; but because it is associated with vicious sur¬
roundings and productive of vicious results, the whole ques¬
tion is apt to be shelved, by some of even the most earnest
philanthropists, as wholly vice, and consequently without
the pale of consideration. Much more should vice and crime

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be regarded as the direct result of excessive drinking, in a
large majority of instances, and excessive drinking as the
external evidence of a morbid nervous condition, the victims
of which more justly claiming assistance and help than re¬
pulsion and neglect.

Returning to our work here, vre have completed a quiet
and useful year. Many patients who have left us have
derived full benefit from their residence, and it may interest
you to mention that two patients of whom I had lost touch
(one hitherto classed as “not heard from ”) have turned up
to report themselves, after periods, respectively, of four and
seven years’ total abstinence.

The house and buildings generally have been maintained
in good repair, and the heating apparatus, fitted to work¬
shops and concert room, has been of great value in adding
to the comfort of the patients.

The general health of the inmates has, throughout the
year, been uniformly good, and no case of serious illness has
occurred.

CANNABINOMIA.

Thomas Ireland of British Guiana, October, 1893, states
that the Coolie immigrants introduced Indian-hemp intox¬
ication into British Guiana, importing the seeds for cultiva¬
tion. The drug is used by religious fanatics as an excitant
to deeds of sacrifice or violence, and was taken by Sepoys,
in the Mutiny, to increase their courage.

Comparatively few females have given way to the indul¬
gence. Mohammedans are rarely addicted.

Wise of the Dacca Asylum, in 1873, stated that in Indian
asylums, on an average, between 30 and 50 per cent, of
admissions were due to abuse of Indian hemp, and that at
the Cairo asylum one-third of the admissions were due to
this narcotic.

In British Guiana fully 30 per cent, of the Coolie patients
in the Barbice asylum had been habitual smokers of can¬
nabis.

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Rich and poor Hindoos alike indulge, bhang being the
cheapest form.

Water is added to the ground leaves and stalk till a liquid
paste is formed, which is strained through a cloth ; § to i
drachm (2 to 4 grammes) is mixed with milk and sugar and
then drank. The poor add black pepper.

The effects are quiet, pleasant delirium and stupor.
Churrus causes excitement and violence.

It is the dried, sticky resin extracted from all parts of the
plants, especially from the pith within the stalk. It is
mostly imported into India from Persia and Afghanistan.
The color is greenish black, the taste bitter, and it is smoked
with or without tobacco in a cigarette on a hookah over
glowing charcoal, after having been rubbed down fine with
the hand. Upla, or cow-dung fire, is preferred to charcoal,
on which the pill or bolus is placed, and the smoke forcibly
drawn through the pipe and then inhaled. One puff some¬
times makes the eyes red, four puffs make a moderate
smoke, | drachm (2 grammes) being sufficient for two or
three men.

Majoon, a dirty, greenish toffee, is another preparation
of cannabis, made from the ground leaves mixed with butter,
sugar, and milk, and then baked. About an ounce (30
grammes) is eaten at a time, and this sweetmeat is often
used by thugs or thieves as a poison in India.

Ganje is made from the dried flower tops rubbed to a
fine powder in the hands, and then smoked in a native clay
pipe mixed with tobacco.— Annual of Medical Sciences.

In accordance with a bill passed by the present Con-
gress, Carroll D. Wright, United States commissioner of
labor, has begun the work of investigating the liquor traffic
in relation to its moral and scientific effects in the industrial
world. His report, which he hopes to present to the fifty-
fourth Congress, will be awaited with equal interest by liq-
uorites and prohibitionists.

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TETANUS FOLLOWING REPEATED INJECTIONS
OF MORPHINE.

The May number of the Medical Chronicle contains the
following account, by Dr. D. J. Leech, of two cases of teta¬
nus which came under his observation : The first case was
that of a man, thirty-five years old. Two days before the
author saw him he complained of pains in the muscles of the
neck. Tetanic paroxysms very soon set in, and on the
afternoon of the third day they occurred at frequent inter¬
vals, and were quite characteristic. He died a few hours
afterward.

He had not suffered from any injury, but he had con¬
tracted the habit of injecting himself frequently with large
quantities of morphine, and after death, marks left by the
injection of morphine were found all over the anterior sur¬
face of the body. The thighs especially were closely cov¬
ered with nodules, some of which were dark at the top.
The lower part of the abdomen was less closely covered by
them. There were no ulcerations, but here and there some
cicatricial tissue. Several dirty syringes for the injection
of morphine were found, and one or two bottles containing
turbid morphine solution. The patient had been in the
habit of injecting into himself considerable quantities of
morphine, and there was reason to believe, says the author,
that he had paid but little attention either to the cleanliness
of the syringe or the clearness of the solution he used.

The second patient was under the care of Dr. Elliott of
Rochdale, who had given him morphine occasionally for four
years, but, finding that the man had begun to purchase mor¬
phine for subcutaneous use by himself, had refused to give
him any more, and nothing was heard of the patient again
until February in this year, when Dr. Elliott’s partner, Dr.
Brooks, was sent for, and found the man suffering from vio¬
lent tetanic paroxysms, from which he died in a few hours.
The illness dated only from the previous evening.

He had not suffered from a wound or injury of any kind,
but the body, arms, and legs were found covered with marks

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due to the hypodermic injection of morphine. No ulcera¬
tion could be found, but in many places there was cicatricial
tissue.

Several somewhat similar cases, says Dr. Leech, have
been placed on record. In the British Medical Journal for
November, 1879, there is an account of the death of a woman
from tetanus, who had long administered to herself subcuta¬
neously large quantities of morphine. The front part of the
body was covered with innumerable scars from the punc¬
tures caused by the hypodermic needles.

Osborne ( British Medical Journal , July, 1892) records
the death of a man, aged twenty-four years, from tetanus
which was evidently connected with a suppurating sore near
the right shoulder, following the hypodermic use of mor¬
phine. This man, too, had been in the habit of injecting
himself with morphine.

A series of cases, says Dr. Leech, have also been re¬
corded of tetanus occurring after the subcutaneous injection
of quinine, and Dr. Anderson, in the British Medical Journal
for 1892, states that tetanus is by no means uncommon after
the use of the hypodermic needle.

It is worthy of note, says Dr. Leech, that in most of the
cases in which tetanus has occurred after the injection of
morphine the injections were self-administered. Habitua¬
tion to the use of the drug, he says, seems to engender care¬
lessness as to the condition of the syringe and the solution
employed.

In England from 1861 to 1871 the mortality of all males
was 11.82 per cent, annually. At 35 years, mortality of all
classes was 13.05 ; laborers, 10.80 ; blacksmiths, 11.24; rail¬
road servants, 14.97; publicans, 20.44.

Inebriety is always rentritional and functional in its ex¬
pression of disorder of the nervous system. It is also a
disease of heredity and degenerative changes, which are
increased by states of poisoning.

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NEURO-RETINAL TOXAEMIA FROM EXCES¬
SIVE USE OF ALCOHOL AND TOBACCO.

Amblyopia, partial or complete, associated with various
nenjous phenomena, simulating cerebral disease, is an affec¬
tion more often met with than is supposed; it is probably
more prevalent with male than with female, not on account
of sexual differentiation at all, but because of the fact that
these and other similar drugs may find their way into the
system by habitual use in men more than in women.

From the fact that not all of the symptoms are referable
to the eye, and from the further fact that the amblyopia
comes on as a later symptom, sometimes long after the other
manifestations have become well marked, we find that these
cases are easily mistaken for cerebral affections, and treated
as such, thereby allowing much valuable time to be lost
before the true nature of the affection is discovered.

The deterioration of vision from the abuse of tobacco
has long been known as a clinical fact, although it was not
well understood, and no very clear explanation, based on
anatomical and physiological ground, have been given. The
action of tobacco, for instance, in different individuals is so
various and uncertain, some persons apparently becoming
immune, as it were, to its toxic effects by long usage, while
others give earlier evidence of its ill effects in nervous
tremors, cardiac, and other disturbances, that we have no
certain landmarks to guide us in our relations as physicians
to those whom we know to be more or less given to its use.
Moreover, amblyopia from alcohol, as a rule, is not so preva¬
lent in those individuals who are classed as inebriates ; in
such persons we find that periodical excesses are followed
by intervals of freedom from its use, during which the pro¬
cess of elimination goes on quite readily, and nature comes
to the relief of the patient so completely as to leave behind
but very little traces of its effects. It is, however, in the
habitual, though not excessive, drinker that we find the evil
effects of alcohol on the eye. In Europe, on the continent,
where the laboring classes are accustomed to rise early and
Vol. XVIII.—42

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seek their employment with a very light breakfast, some¬
times not eating for an hour or two after they rise, they are
in the habit of taking the early morning draft of “ liquer ”
or “ schnapps ” upon going to work, and at nine or ten
o’clock stopping for a half hour or so for breakfast. In this
country also, while we find no such habits of life among the
laboring classes, yet there are many individuals who do take
spirits early in the morning before they eat their breakfast,
and follow this practice for years. They are not classed as
drunkards ; on the other hand, bear the opposite reputation;
but with all that will be found on close examination to be
steady drinkers.

Concerning the treatment, but little need to be said
beyond the first and most important point, viz., the estab¬
lishing of a clear, rational, and unerring diagnosis; the rest
follows “Ex necessaria sequitur” Total separation from
the toxic agent in question once and for all; in the case of
lead this will be easy enough in most instances, but with
tobacco and alcohol not so easy. Resolutions and promises
made in good faith will frequently be broken. Alteratives
among the drugs will avail something, among which we hale
iodide of sodium, strynchnia nitrate, by hypodermic injec¬
tion will accomplish much, and electricity and the Turkish
bath will avail. The insomnia which so frequently accom¬
panies these cases should be controlled, but this will usually
give way to refreshing sleep as the improvement from the
other remedial measures progresses. The prognosis is in
many cases good, but much time may be consumed, and
great patience be required, both on the part of the patient
and the doctor, before a final recovery occurs.

Kirchhoff says: We know nothing of the anatomical
basis of epilepsy. Its most frequent cause is heredity, then
follow alcoholic excesses. Next come cerebral diseases in
early childhood. Concussion and physical and psychical
traumal are also causes.

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ACTION OF TEA ON THE DIGESTIVE ORGANS.

An interesting account is given in the Dublin Medical
Journal for October of Dr. Peter M’Kechnie's experiments
on the action of tea on the organs of digestion. The experi¬
ments were carried out partly in test tubes, partly in the
stomach of a monkey, access to which was formed by a
fistula.

The aliments experimented with consisted of egg-albumen
and beef-fibre. Weighed quantities of each were used, and
were mixed with glycerol extract of pepsin and hydrochloric
acid. To these mixtures a measured quantity of infusion of
tea was added. The infusion of the tea occupied periods
varying from five to twenty minutes. Six test tubes were
used, a seventh being employed to test the action of the tea
on meat-fibre alone. That process lasted no minutes be¬
fore the meat-fibre was dissolved. Experiments with the
tea infusion showed that the digestion of the mixture occu¬
pied 118.5 minutes. The time was not affected by differ¬
ence of strength of the infusions of tea. Tea from which
its tannic acid had been precipitated by means of gelatine
was not more readily digested than ordinary tea.

In the case of the monkey it was found that when the
ingesta were altogether introduced through the mouth, diges¬
tion occupied five minutes longer than when the ingesta,
except the tea, were introduced through the mouth and the
tea by the fistulous opening into the stomach. From this
it is to be inferred that the tea exerted an inhibitory influ¬
ence on the salivary glands. The author is of opinion that
it is not the tannic acid, but some of the more soluble con¬
stituents of tea, which retard digestion.

The comparative values of different kinds of teas were
investigated. The Indian and Ceylon teas yielded the
greater proportions of extract, i. e., made stronger infusions
than the Chinese teas. Digestion took place more rapidly
when the stronger infusions were used. The author believes
that the larger proportion of caffein in the Ceylon and Indian
teas as compared with the Chinese teas is the cause of the

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more easy digestion of the former, the caffein acting as a
stimulant to the motor nerves, and increasing the flow of
bile, and stimulating peristaltic action.

Dr. M’Kechnie does not share the somewhat general be¬
lief that, on the whole, tea is not a wholesome beverage. I
agree with this opinion. Since the general use of tea has
been adopted in these countries the state of public health
has not deteriorated, but, on the contrary, has improved.
Dr. E. Smith, in his work on “ Health and Disease, Etc.”
(London: Walton & Maberly, 1861), says of tea, that “it
has both lessened the supply of nutriment and made better
use of that which is supplied, and hence it has contributed
most powerfully to the prevention of accumulations within
the system, and the most perfect discharge of effete
matter.”

Dr. M’Kechnie deprecates the practice of infusing tea
for more than five minutes, and states that by twenty min¬
utes infusion the tea yields a much less wholesome beverage
than if it were infused for a moderate time. As the tannin
of tea, being very soluble, soon goes into solution, it would
be interesting to determine the nature of the body or bodies
which are dissolved out by long-continued digestion, and
which have a bitter flavor. — Times and Register.

AN ISLAND INEBRIATE HOME.

Medical Island is the name which has been given by a
syndicate of physicians from New York, Paris, London, and
Berlin to a tropical island of volcanic origin eleven days’ sail
from San Francisco. Here is to be elaborated a model san¬
itarium for the cure of the drink and opium habits.

There will be no hotels or boarding-houses, but in their
stead there will be three handsome club-houses without bars.
Patients must consent to remain away from the continent
for one year and pay all expenses for that time in advance.

The island is under the jurisdiction of Great Britain,
from whom the syndicate will secure its needed concession.

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HYGIENIC TREATMENT OF DIPSOMANIA.

By Dr. H. M. Wyman.

Neurologists as yet have failed to find any special medi¬
cine for the cure of dipsomania.

Total abstinence with enforced confinement for an in¬
definite period is effectual while the confinement lasts, and
has in well-authenticated instances proven a permanent
cure, when the patient on his release has been environed by
conditions conducive to his material prosperity and happi¬
ness. Just what treatment should be enjoined aside from
the old line outlined, together with suitable and congenial
employment (the latter of paramount importance) during
the long period of seclusion, is a matter not a little perplex¬
ing when looking forward to a permanent cure. With its
long time commitments, the Massachusetts Hospital for
Dipsomaniacs and Inebriates at Foxboro has exceptionally
good advantages for the employment of methods of treat¬
ment hitherto untried, the nature of which is indicated by
the caption of this article.

It was the privilege of the writer to witness th^initial
introduction of calisthenic exercises and the accompanying
needle bath as a feature experimental in the treatment of
dipsomania at the above institution some eight months
since, and judging from up-to-date results, the enthusiasm
is pardonable, if premature.

From the heterogeneous gathering of humanity to be
found in an institution of this character, with the concomi¬
tant infirmaries arising from the excesses that resulted in
their presence here, it was not an easy task for Prof. Boos,
of Boston, to select a considerable number eligible to take
the exercises. However, excluding those whose mental and
physical conditions unfitted them entirely, a class of some
sixty were enrolled to take the calisthenics daily.

With a fairly well equipped gymnasium and campus for
outdoor games, the patients, after some hesitancy and coer¬
cion, soon began to manifest an interest unlooked for, until

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now, fully aware of the benefit derived, they are loath to
neglect the exercises.

Statistical evidence from actual measurements as to in¬
crease in muscular development is, up to date, very gratify¬
ing, and as time goes apace the results in this direction are
obvious.

The all-important change for the better is apparent in
the feelings and appearance of the patients. The calisthen¬
ics, with the necessary apparatus, have, with their variety of
movements, brought into action separate sets of muscles,
that from inaction have impeded the functions of others,
and have become practically useless* themselves. The
shambling and faltering step, the stooping shoulders, the
blear-eyed, expressionless-faced victims of former excesses
have given place to the certain step and supple movements
— perfect control of movements governs the body — while
the eye has luster, and the mobile face, with erect bearing,
denotes interest in life and hope in the future. Without
going into the pathology here of inebriety, it is sufficient
for practical purposes to know the physiological needs of
the unfortunates: that the inebriate is very apt to have or¬
ganic or functional lesions of visceral parts of varying de¬
grees of gravity is to be expected and judiciously prescribed
for, but that the brain and nervous system are the chief
deciderati, especially when anticipating a permanent cure.
Calisthenic exercises, as scientifically supplemented by
wholesome food and regular hours of rest, are accomplishing
wonders. The daily exercises are systematized, and as the
varying movements with Indian clubs, dumb bells, chest
weights, parallel and horizontal bars, together with bag
punching, boxing, running, jumping, balancing, marching,
and outdoor ball games go on, blood and tissue metamor¬
phosis is taking place , and the excrementitious products of
the body are being eliminated , while nervous co-ordination
and reflexes are improved, and the former neurasthenic con¬
dition is succeeded by a feeling of strength and security
that better enables the unfortunate to resist the enemy .

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The carefully temperatured needle bath—consisting of hose
and spray attachment—following the exercise, cleanses the
body of its transudations, reawakens nervous energy from
periphery to center, heightens capillary circulation, and, the
body gradually cooling, a feeling of buoyancy and strength
pervades the entire system that is not followed by a stage
of depression. Thus tissue change takes place from scien¬
tific exercise; the waste materials are eliminated, and fol¬
lowed by wholesome food and rest, the morbid condition
gives way to health and happiness. The intricacies or com¬
plication incident to the various exercises is a school for the
mind as well as the body. The full term of commitment at
the institution is for two years, but discretionary with the
Board of Trustees as to a patient’s fitness for leave of ab¬
sence in a much less time, the usual time being six months.
Having taken the exercises is a prime requisite to an appli¬
cant obtaining a leave of absence at the expiration of his
first six months.

To Prof. H. D. Boos of Boston is due great credit in
awakening apathy of inmates, and for his patient efforts in
bringing such tangible evidence to the Board of Trustees of
the beneficent results to be obtained from calisthenics in
the treatment of dipsomania .—Journal of Hygiene .

SOME CAUSES OF MENTAL IMPAIRMENT IN
CHILDREN.

Dr. J. M. Taylor of Philadelphia, in a very valuable
paper on this subject, concludes as follows:

In order, then, to prevent mental enfeeblement in the
young we must first defend them from degenerating influ¬
ences of a kind competent to leave a permanent impairment
upon the individual or the offspring. Next, if this be done,
opportunity must be afforded for the development of both
body and mind, which are absolutely interdependent.
Again, protection must be afforded against accidental
injury by trauma or poisons.

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Of the degenerating influences, alcohol stands at the
head, and admittedly accounts for nearly one-half the cases
of insanity, imbecility, and crime; but if one considers
fairly that the other causes, usually acknowledged, are
themselves attributable to this agency, these must then be
added to the other, and the blighting influences of alcohol
are thus multiplied till they may be said, without exaggera¬
tion, to overtop all other factors many times. The use of
alcohol causes degeneration of mind and body in the indi¬
vidual, and is pre-eminent in transmitting its influence to
the next generation. Alcohol produces not only disorders
of intellectation, but of morals, hence it becomes the basis of
criminality. Moreover, alcohol admittedly decreases the
power to resist evil and disease, and this increasingly from
one to another generation. Lack of resistance to evil pro¬
duces the criminal, the enemy of civilization, both in a
moral and physical sense. Loss of resistance to disease
opens up the way for other morbid influences, as tubercle
and the various infectious processes which are themselves
direct and contributory causes for degenerations and for
mental defects.

This is, however, rarely true of an entirely sound cellular
entity. The feebly resisting nervous system needs rela¬
tively little help from disease, trauma, or the various excita¬
tions to dethrone equilibrium. A sound, wholesome
organism, on the contrary, may be predicted to pass
unscathed through many and diverse perils, certainly so
far as the competence of its nervous mechanism is con¬
cerned.

The so-called reflex causes of mental disease, including
psychical and moral shock, etc., may be reduced to small
power for harm upon robust natures, of^ stable cellular
integrity and reasonable development.

Once the seeds of mental derangement are recognized
as evidencing growth, the only hope for adequate repair
lies in instant precautions, ample safeguards, and years,
rather than months, of rest, and the enjoyment of responsi¬
bilities as little as possible.

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THE NON-HEREDITY OF INEBRIETY. By Leslie
E. Keeley, M.D., LL.D. C. C. Griggs & Co., Pub¬
lishers, Chicago, Ill., 1896.

Sudden prominence achieved through pretension and
mystery often brings with it a fatal egotism, which forces
the person out into the light where his knowledge and at¬
tainments can be seen and estimated. In politics many a
local celebrity has been destroyed by placing him in office,
where his real capacity and power can be studied above the
glamor of pretense.

The Keeley Gold Cure scheme and its author were se¬
cure as long as its claims depended on the statements of
circulars, newspapers reports, and the assertions of the
founder and his friends. But when he writes a book he
steps out into the light, where his knowledge and theories
can be properly estimated. In this Keeley has committed
the same old blunder, writing himself down, and putting
himself into the hands of his enemies. If he had limited
his writing to a general statement and defense of some ra¬
tional theory of inebriety, and its non-heredity, his work
might have had a place in the literature of the day. But to
attempt to dogmatically decide great questions of ethics,
biology, physiology, psychology, and history, is a fatal ego¬
tism that is literally a “ hari-kari ” for the writer.

It seems useless to examine the theory which this work
pretends to defend, because many of the statements urged
are notoriously false and untrue, and the suggestion that it
is due to the ignorance or duplicity of the writer, leaves an
unpleasant impression on the mind of the reader.

Statements like the following are common. “ Before
the discoveries of Dr. Koch no one could explain what
caused disease, or what determined its phenomena, duration,
and termination/' p. 35.

“ The human mind has fathomed the universe scientific¬
ally, and determined its own limits of understanding and
comprehension/' p. 91.

Vol. XVIII.—43

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“ Until within a few years no treatment except mind
cure has ever been tried for inebriety.” p. 97.

“ Alcohol causes inebriety; there is no other cause of
alcoholic inebriety.” p. 183.

“ No heredity or other disease can cause or is inebriety.
Any disease may lead a person to begin drinking, but no
agent except alcohol can cause inebriety, nor will the cure
of any other disease associated with it, or caused by alco¬
hol, necessarily exert any influence whatever either for or
against the craving for drink.” p. 167.

“The cure of inebriety cures the inebriate’s stom¬
ach.” p. 173.

“ I consider myself a pioneer in the department of path¬
ology and therapeutics. I think the medical profession
will give me the credit of studying this subject from the
standpoint of pathology. When I began I was the only
man in the world who was treating drunkenness as a dis¬
ease, exclusively, from the standpoint of medicine.” p. 305.

The central theory seems to be that inebriety is a germ
disease which cannot be transmitted, but is positively cured
by the specific which the author possesses, and believes he
should conceal from others as his private property. Wheth¬
er this work is written for the laity or the medical profession
it is remarkable in that it marks the death and obsequies
of its author and his schemes for the cure of inebriety.
There is no necessity now of making known his formula of
specifics given for the cure of ninety-five per cent, or more
of all cases of inebriety. He has given the theory in this
work together with his views of science and ethics, and
other general topics, and all the mystery and pretense has
vanished. Leslie E. Keeley and his specific for the cure of
inebriety have passed into history as one of the great cre¬
dulities of the closing century. The egotism which sup¬
posed he was the creator will die away, and the student of
the future will study the psychological conditions which
gave transient prominence to a wild delirious empiricism.
All unconsciously Keeley has been an instrument to arouse

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up a new interest in the physical treatment of inebriety,
not by his specifics but by educating the public to accept
the idea of help along lines of physical means and applian¬
ces. Now all unconsciously, in this book he writes his own
epitaph, and pronounces the last word at the close of the
Gold Cure specifics for the cure of inebriety. The curtain
falls on Keeley as a teacher, writer, and physician. The
Gold Cure is dead, and a period of mourning and frantic as¬
sertions that* life still exists will follow for some time to
come.

The Second Book in Physiology and Hygiene , by Dr. J.
H. Kellogg of Battle Creek, Michigan, is an excellent group¬
ing of well-known facts, with special reference to the hygi¬
enic application. The action of alcohol on the tissue is very
clear and well-stated.

The Dixon Graphite pencils are superior to any on the
market. All grades of hard and soft pencils are made.

Dr. Kellogg’s work, “The Stomach, its Disorders and
How to Cure Them,” has become an authority at once. The
critics call it one of the great works of the year.

The Popular Science News , formerly Boston Journal of
Chemistry and Hall’s Journal of Health, has succeeded in
combining the best features of these and other journals, and
giving a r6sum6 of the most practical facts from all fields of
science. For short, popular facts, it is one of the best jour¬
nals published. The price is one dollar a year. Address
19 Liberty street, New York city.

The Thirty-eighth Annual Report of the Washingtonian
Home y Boston, Mass., indicates a prosperous year, two hun¬
dred and forty-five patients being admitted. A very signifi¬
cant fact is that in this large number of cases only fifteen
were delirious or suffering from delirium tremens, — a clear
hint of a change of the type of cases. The superintendent,

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Dr. Ellsworth, in speaking of the effects of alcohol, makes
the following significant statements : —

“ Drink lends excess of coloring to some ideas, and im¬
parts dullness to others. Alcohol renders the brain more
and more incompetent as a thinking and reasoning medium.
Inebriates always become more or less demented. They
may degenerate so slowly, both physically and mentally, as
not to exhibit grades or degrees of decline from day to day,
yet after a time a marked change for the worse occurs in all
cases. . . .

“ The moderate drinker may escape a precipitous fall, yet
he too, in the course of years, will be conscious of physical
and mental degeneration that cannot be logically ascribed to
other causes of decline. . . .

“Just according to the extent that the brain and nerves
are paralyzed, is the drinker incapable of judging correctly
of anything, and, least of all, of giving a proper estimate of
the paralyzing agent.”

This excellent asylum is doing grand work, fully sustain¬
ing its old-time reputation.

The Homiletic Review , published by Funk & Wagnalls,
grows more valuable with each issue. Its terse and suggest¬
ive papers are unexcelled, and should be read by all scholars
of the new philosophy and thought of the age.

Appleton's Popular Science Monthly , among the many
excellent papers published, gives great prominence to medi¬
cal and psychological questions. The papers by Prof. New-
bold are the most suggestive and valuable to medical men.
No other journal excels this in practical interest and real
value to every thinking man.

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SjditoriM.

INEBRIETY AND HOMICIDE.

Dr. Andrew White finds that there were over ten thou¬
sand homicides in the United States in 1895,— two and a
half per cent, more than in 1890, and constantly increasing.
He is convinced that the leading cause is a lax public senti¬
ment and failure of the law to punish criminals for this
crime. Judge Parker of the United States Court has taken
up this subject and reaches the same conclusion, only he is
more emphatic in his conviction that the law’s delays and
uncertainties, with mock sentiment for the criminals, encour¬
age murder. Other causes are noticed as contributing, but
of minor interest, such as the degeneracy and low criminal
emigrants from Europe who commit murder from slight
provocations.

Both of these studies assume that the treatment of the
crime of murder is correct, and all first causes and means of
prevention insignificant.

The statistics of the failure of capital punishment to
prevent murder, so positively urged by earnest, capable men,
are ignored as if unworthy of notice. An appeal to facts of
cases of homicide reveals a different view of this subject. In
ten homicides in and near Boston, eight were committed
while under the influence of alcohol. Three were clearly in¬
sane and sent to prison for life. Of the seven, two were
hung, one was liberated after a year’s confinement, and four
are now in prison. Five of these cases were notoriously
dangerous and maniacal when drinking. Of the others a
history of degeneracy and continuous drinking for years was
clear.

In six homicide cases in Connecticut, five were com¬
mitted while intoxicated, and one was hung — the others are

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in prison. In twelve cases in New York, nine were promi¬
nently intoxicated at or before the homicide. These facts
represent in a general way the condition of a very large per¬
centage of the ten thousand murderers of 1895. The state¬
ment that from sixty to eighty per cent, of all murders in
this country are the work of inebriates and persons under
the influence of spirits, has been confirmed in many ways
beyond question. Here are causes that these authors have
not noticed.

The punishment of inebriates by death for crime has
been repeatedly proven worthless. Increased vigor and se¬
verity of punishment has never stopped inebriety or checked
crime by inebriates, because it failed to reach the first
causes. These causes are the freedom allowed inebriates to
go about freely, using spirits at all times and places without
control, and the open licensed saloon encouraging and mak¬
ing attractive the indiscriminate use of spirits. The first
causes, heredity, anaemia, exhaustion, mental defect, and
degeneracy, are intensified and exploded by the saloon. Like
the powder and lighted match, the degenerate finds relief in
the narcotism of alcohol, and although the dissolution goes
on under a mask, it is certain and inevitable.

Homicides of necessity will increase yearly, uninfluenced
by the administration of law or sympathy for the offender,
because the causes are unrecognized. If murders are most
frequently caused by inebriety, and inebriety intensified and
developed by the open saloon, the remedy is clear. If the
degeneracy of inebriety predispose to crime, the inebriate is
dangerous and should come under legal control before crime
is committed. In many cases of homicides by inebriates
the crime was clearly foreshadowed and was certain to oc¬
cur, in favorable circumstances.

Rational preventive medicine will lock up the inebriate and
shut up the saloon, and thus prevent the crime. A new study
of this subject is essential before causes and remedies can
be mentioned authoritatively. Who are these ten thousand
murderers of 1895 ? What were the conditions of the crime?

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A study of these facts will reveal the means of prevention
and the proper remedies. All theories and speculations on
other lines are farcical and absurd.

TWO THEORIES, WHICH ONE IS TRUE?

A noted man was arrested for incendiarism and found
guilty. No reasonable motive was apparent; the property
burned was that of a stranger to him, and he appeared at
the fire, giving all possible assistance to extinguish the
flames.

This man had been a moderate, and at times an exces¬
sive, user of spirits. Occupying a very prominent office for
many years, he alternately pleased and disgusted his friends.
At times he was able and generous, then reckless and wild
in his conduct, associating with fast men and women, spend¬
ing money lavishly and involving his friends. Finally, he
resigned on the plea of ill health, a*nd became a low politi¬
cian. His drinking increased and he was intoxicated most
of the time. Later, he was detected putting fire to a build¬
ing, and although the evidence was not clear, yet the sus¬
picion of other similar acts was very strong. He was exam¬
ined for lunacy, and decided perfectly sane by two medical
men. His friends applied to a state asylum for admission,
but were refused. A few months later he was found to be
insane and sent to an asylum. The interval had been spent
in severe drinking. The theory that this case was simply
one of voluntary drunkenness, in which bad company and
political excitement, with reckless neglect, were the only
causes, was accepted by his friends and the public generally.
Before entering upon political life he had been a quiet
church member and steady, reputable man, with a large
circle of friends who respected him greatly. The medical
certificate of his insanity was laughed at as a political
scheme to provide for him in the asylum, and the medical
men as kind, accommodating friends.

The Other side of this case presents a different theory

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of his condition. His grandfather died insane after a life¬
time of excessive drinking. His father kept a roadside tav¬
ern and drank freely at times. His son sold spirits at the
bar, and drank freely in early life. On the death of his
father the business was given up, and he abstained. Marry¬
ing at this time, he settled down to a quiet, steady business
life. At forty-four he was elected to a prominent office by
accident. A few years later he was re-elected, and became
a prominent politician. From this time he began to have
secret drink paroxysms of several days* duration, and was
noted as a fast politician.

Resigning from office, he returned and spent his time
in political circles as a man-of-all-work, “rounding up the
voters/’ and arranging campaigns for others. His use of
spirits was excessive at times and was followed by melan¬
choly. On two different occasions he suffered from alco¬
holic mania for periods of a week, then recovered, but never
totally abstaining. His only son became a confirmed ine¬
briate and his wife an invalid; this, with poverty, increased
his mental disturbances.

The first medical commission could not find any mental
disease, and the asylum superintendent concurred in this,
although it was proven that he had delusions of sudden
death at night in sleep, and this, with insomnia, caused him
to walk the streets at night, seeking company of any one
who would talk to him. In the morning he would go home
and sleep.

The second commission, two months later, recognized
delusions and melancholy, and he was committed to an
asylum.

The inebriety , in this case was clearly an inheritance,
which appeared in early life, then subsided and broke out
again under the favorable conditions of political life. The
pyromania which appeared was a marked sign, and a closer
examination would have revealed other defects. He was
suffering from the disease of inebriety, which had become a
pronounced insanity, and was not in any way a voluntary

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condition within his control. Given the heredity and con¬
ditions of early life, and inebriety was almost certain to fol¬
low. Manias of any form were likely to develop as the
degeneration increased. His political life was favorable in
its surroundings for the growth of inebriety. There were
no accidents, or chances, or moral conditions in his case.
No moral theories can account or explain the progress of
the case. There ought not to be any question as to the
causes and nature of such cases.

THE TREATMENT OF RELATIVES OF INE¬
BRIATES.

The paranoic and degenerate inebriate is regarded by
his relatives generally as a very bright, capable person, who
voluntarily gives way to the morbid impulses of the moment,
and one who could always do better with more will power.
He is considered sane at all times when not drunk, and able
to judge of his condition as clearly as any one. The drink
impulse, like a garment, can be put on and off almost at the
will of the victim and surroundings: The honesty of the
patient is unquestioned when not drinking. On admission
to an asylum severe measures are demanded by the relatives,
or great leniency. Punishment, fear, and alarm must be
roused in the mind of the victim ; or great tenderness, love,
confidence, and trust. The friends assume to be able to
judge from intimate acquaintance what is best in treatment,
especially in matters of restraint and general care. The in¬
ebriate soon learns the conceptions of his relatives regard¬
ing his case, and where they are in accord with his own
views of perfect freedom and trust, and power to decide on
what is best for his case, are fostered industriously. But
where they they are opposed to his views, he resorts to
intrigue and cunning to neutralize them.

The rules of the asylum are always in conflict with either
the patient or his friends. The patient is controlled, but the
friends at a distance are difficult and uncertain.

Almost endless correspondence and explanations are
Vol. XVIII.—44

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required constantly. Often the patient joins to complicate
and increase the difficulty. He will write of his great temp¬
tation and power of resistance and the free use of spirits in
the asylum by every one. The explanation by the managers
are doubted, and the patient’s statement is considered true
in part or entire.

The mercenary motives of managers are always promi¬
nent in advice to stay longer. Consent to do this or that is
supposed to have some similar object or purpose. Fears
that the management may acquire undue influence over the
patient, and keep him away from his family, or if he has
property influence him in some way to his future injury. If
a patient relapse the management are condemned as crimi¬
nally negligent, or wanton; if the patient has manias of
slander and intrigue, and complicates matter about him seri¬
ously, the management has failed. If after a few months
stay, during which the patient has done well, his cure is not
confidently predicted, the management is at fault. Should
the patient have proved incurable and received but little help
it is equally a fault of the management. Thus the managers
of asylums often have a more difficult task to educate, teach,
and treat the relatives of inebriates, than to care for the pa¬
tient. Most relatives of patients seldom realize the unstable
defective brains of inebriates. The degeneration of the
higher centers, the depressed and disordered sense, with
enfeebled powers of reasoning, are concealed by the assump¬
tion egotism of the patient. The idea of brain disease
other than temporary functional disturbance is put aside as
not true.

Happily, these views are passing away, and relatives of
patients understand in some way, that inebriety is insanity,
and the inebriate is diseased, and irresponsible on all matters
pertaining to his own case.

The managers of asylums look forward to the time when
the treatment of relatives will pass away, and patients placed
under care can be effectually treated, controlled, and guided,
without counsel and interference from those who now
assume to know what should be done.

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NEWSPAPER TREATMENT OF INEBRIETY. .

In a small section of the New England States four
murders occurred within a month. In each instance
the murderer was an inebriate, and the crime was com¬
mitted in the delirium of intoxication. The newspapers
of that section claiming to represent public sentiment
were violent in their denunciation of inebriates and the
lax laws which failed to punish severely all persons
who drank to intoxication. Speedy and most summary
capital punishment was demanded. One paper suggest¬
ed lynch-law as a means of intimidating other offenders.
One case of a farmer who had been placed in an asy¬
lum two years before, and was taken out on a writ, as
unjustly confined, had been the subject of much com¬
ment and condemnation of laws which permitted any one to
be confined on small pretense. The papers said his drink¬
ing was not insanity, and he was fully sane, and it was
great injustice to confine such men in asylums. Now that
murder had followed nothing could be too severe in punish¬
ment. The §econd case had been repeatedly sent to jail for
ten days for assaults when intoxicated. He was considered
sane and responsible, and should not be locked up long.
The third case was a periodic, who at intervals drank to ex¬
cess, and had been sent to jail for disturbance. The fourth
was a cider-drinker of notoriously bad temper, and very un¬
reasonable and dangerous man at times. Two of these
cases were clearly insane, and of defective brain control,
when not using spirits. The other two cases were deliri¬
ous when drinking, and without control of themselves, or
conscious of the surroundings and their relation to it. All
of them were unfit to be at large, and almost certain any
time to develop acute mania from the slightest exciting
causes. The certainty of crime in each one of these cases
was beyond question. It was simply a matter of circum¬
stances and conditions which were sure to occur sooner or
later. The folly of permitting men of this character to go
about unrestrained, and when crime follows demand pun-

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Editorial ’

ishment, should come to an end. The time is near when
crime of this class will be prevented by placing such men
under restraint and demanding sobriety as the price of lib¬
erty and freedom. Public indignation, after the commission
of the crime, is childishness. The public should demand
the removal of all conditions favoring crime in advance.
No man should be permitted to poison himself, and become
insane at any time and place. The removal of the causes
of crime should be the treatment urged by the papers.
This is the way to effectually “ stamp out 99 and lessen crime
of all descriptions. Shut up the inebriate and drinking
man who persists in using spirits of his own free will, and
all times. Punishing these four murderers, before the com¬
mission of the crimes by short sentences, and hanging them
after, is monumental stupidity in this day of civilization.
The newspaper treatment of inebriety reflects the sentiment
and theories of an age of ignorance, which fortunately is
fast passing away.

PRECOCITY IN CHILDHOOD, FOLLOWED BY
INEBRIETY.

Many of the most degenerate inebriates have a history of
precocity in early life. This occurs often in families in
which the father is a moderate or periodic drinker, and the
mother a nervous, highly sensitive woman, whose inteli-
gence has roused a fear of heredity. Both parents may
watch with anxiety the early developments of the mind of
the child, and any form of precocity is encouraged as evi¬
dence that inheritance of any weakness will not appear in
this case. In a single instance an intelligent physician who
was a moderate drinker, and whose wife was a neurotic, had
a son who prepared for college at ten, and who was a prodigy
in memory and intellect. He was a poet and mathemati¬
cian of fair physical development. He graduated at sixteen
with the highest honors, and at twenty entered the medical
profession with great promise. The death of his father
brought him a large professional business, which he seemed

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289

incompetent to conduct. He became despondent and mel¬
ancholy, and suddenly drank spirits and used morphine, and
died two years later from excesses. In early life he was
encouraged by his parents, who believed intellectual train¬
ing and eftrly development would overcome any inherited
weakness which might have been transmitted from them.

The frequent wrecks of prize and honor men of colleges
and universities suggest precocity and bad inheritance
The sentiment prevalent in many colleges that wine gives
intellectual power and mental clearness, is fatal to many
precocious students, who in the stress of later life turn to
spirits for help only to become wrecks. Precocity and ex¬
treme mental or physical development in the children of
drinking ancestry are frequently signs of early failure and
physical disaster. A noted surgeon and moderate drinker
sneered at the doctrine of heredity, and pointed to his pre¬
cocious and highly developed son as evidence that the fath¬
er’s conduct had no influence in his organization. Two
years later he died of delirium tremens.

It may be stated, as a general fact, that the phenomenal
young men and women who astonish and delight their
parents and friends with extraordinary attainments are
doomed to any early death, and inebriety, hysteria, and vari¬
ous forms of insanity associated with exhaustion are almost
sure to precede death. Inebriety seems most common, par¬
ticularly of narcotic drugs, and especially where any inher¬
ited neurotic tendencies exist. Children showing this un¬
usual development should have unusual care and restraint
to check the mental growth by building up the physical,
and the danger of inebriety should never be overlooked.

It is a curious fact of history, so often repeated and yet
seldom recognized, that the disbeliefs and denials of great
men concerning new facts are often radically wrong, par¬
ticularly when opposed to the observations of men of lesser
note and equal honesty. A denial of the facts by scientific

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Editorial.

or educated men on a priori grounds of absurdity or impos¬
sibility is, as a rule, worthless. The opinions of learned
specialists in nervous or mental diseases that inebriety has
no basis to be called a disease, are still echoed in some
circles as authoritative facts. The investigations of many
persons who are admittedly honest and sane, and whose con¬
clusions have been examined and reaffirmed in many ways,
are more reliable than opinions of learned men who have not
studied the subject clinically.

The true scientific spirit is to ask for evidence and
examine the statements of new facts, not deny and contra¬
dict them. This is the position this Journal has taken in
regard to all the new schemes and theories of the cure of
inebriety. Years ago the moral theories of the vice origin
of inebriety were studied by examination of cases, and found
to be unsupported and untrue. During the last three years
a number of new methods of cure of inebriety by special
specific remedies have been presented for our opinion. In
each case up to the present time the particular value of the
remedy has been found to be in the credulity and faith of its
reception. The mental effect of these remedies are of equal
value to their therapeutic action. All we have examined
are found to be combinations of well-known narcotics, and
concealed drugs of the same nature as those used in the
addiction. Notwithstanding this experience, this Journal
is pleased to examine any new facts and theories which may
be offered. Each one will be treated fairly and scientifically.

The American Association for the Study and Cure of In¬
ebriety was organized November 29, 1870, in the parlors of
the Young Men’s Christian Association of New York city.
In December, 1876, the first number of The Journal of
Inebriety was issued. Both of these events were great
starting points for the scientific study of inebriety. It is
proposed to hold a memorial service in the same hall, to cel¬
ebrate these events and place on record some historic facts

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291

which may be lost in the future. Any reader who may
know of any efforts. to establish asylums in different parts
of the country, or laws passed relating to inebriates, will
confer a great favor by writing Dr. Crothers, the secretary.
An effort will be made to record all the early means used to
rouse public interest in the scientific study of inebriety,
particularly in the sixties and seventies. The time has come
to gather the facts of these pioneer efforts, and leave some
permanent record for the historian of the next century.

TEACHING THE DANGER OF THE USE OF
ALCOHOL IN PUBLIC SCHOOLS.

It is difficult to explain why persons of intelligence not
engaged in the traffic of spirits should oppose all efforts to
combine instruction relative to alcohol with the teaching of
physiology in the public schools. To sneer at the term,
“scientific temperance/’ and to object to faults of expression
and words that are used loosely in text-books, is not scien¬
tific, to say the least. To admit that such instruction is
needed and useful, and object to the way and means of doing
it, is an assumption of superiority that calls for a demonstra¬
tion in something more than words. If the term “ scientific
temperance” is meaningless and faulty, a more accurate
term should be given. If the expressions in the school¬
books are weak, dogmatic, and imply more than the facts
sustain, a correction should be suggested.

In the large number of books which are published to
meet the demand for school instruction of the use of alcohol
as a beverage, it may be said that, with hardly an exception,
the facts they present are true. In the effort to popularize
and make clear these facts much difference exists, mostly of
words and expressions. There is no doubt great improve¬
ment possible, and the same books, after future revisions,
will be materially changed.

If the facts they teach are true, objections of any form

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Editorial. *

will merely reflect the mind of the objector. Like the ques¬
tion of the disease of inebriety, the more violent the denials
the more rapidly the truth grew and was accepted. Oppo¬
sition and criticism may obscure and retard the acceptance
of a truth for a time, but this only brings to it more power
and greater value in the future.

The danger of alcohol which should be taught in public
schools to children is not a matter of theory or sentiment;
it is a necessity which is called for, and cannot be ignored
by whims and personal prejudice. It is a reality that has
come to be a part of the realism of to-day. It has passed
beyond cavil and question, and is accepted as an advance
movement of the age. Its opponents and critics must fall
back and content themselves with discussion far in the rear.
Their frantic shouts of what should be done will never be
heard on the front lines.

WEIR’S INDEX TO THE MEDICAL PRESS.

An index of all the current articles and every book from
every American medical writer, published in a form conven¬
ient and within the financial reach of every physician
(monthly, $3.00 per annum) is something long desired by
the doctors of America. The Journal therefore welcomes
the new publication into the medical field, with a sincere
wish for its prosperity, and a confident hope that the pub¬
lishers, Frank Weir & Co. of New York city, will make a
great success of this most practical work. Send for a
prospectus.

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2 93

JSfote^ £ir|d Comments.

INEBRIETY AND SOBRIETY IN ROYAL CIRCLES.

While statisticians are at variance as to whether the
amount of crime and insanity due to the abuse of stimulants
shows any serious signs of decline, yet they are perfectly
agreed upon one significant and gratifying fact, namely, that
inebriety is each year becoming more and more restricted to
the ignorant and poverty-stricken masses, occupying the
lowest degrees of the social and intellectual scale. While
this is manifestly attributable, in the main, to the extraordi¬
nary progress and rapid extension of popular education since
the last three or four decades, it is likewise due, in no small
measure, to the example set by those who, as sovereigns and
princes of the blood, may be justly regarded as leading the
fashions, influencing the manners, and acting as arbiters of
society in monarchical countries.

Inebriety is no longer fashionable, as it was in the times
of their fathers and grandfathers, when a man who went to
bed sober was regarded with distrust as a moral anomaly,
and the diner who could not put away at least his three bot¬
tles of port at a sitting as unworthy of the title of gentleman.
To-day drunkenness is condemned as bad form, and society,
instead of viewing it with favor, or even with good-natured
indulgence, frowns upon it with every manifestation of dis¬
gust and even anger. For this radical transformation of an
old-time custom and fashion Europe is indebted to those
who act as its leaders in such matters, namely, the Anointed
of the Lord.

Abstemiousness constitutes to-day the predominant note
at every one of the royal and imperial courts of the Old
World, and the rulers who now occupy the thrones of Eu¬
rope are as distinguished for their temperance alike in
Vol. XVIII.—4s

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Clinical Notes and Comments.

drinking and eating as their predecessors were the reverse.
Thus King Humbert restricts himself to wine diluted with
water, whereas his father, King Victor Emmanuel, the “ Re
Galant ’uomo,” was wont to indulge in drunken carouses
with his morganatic wife, the gamekeeper’s daughter, Rosina,
whom he created Countess of Mirafiore, and who used, when
inebriated, to respond to his blows by hurling the crockery
at his head.

The favorite beverage of the Emperor Francis Joseph is
Pilsner beer, which is served to him even at the grandest of
state banquets, at the court of Vienna. He drinks but little
wine, although the imperial cellars are the most celebrated
in the world. Indeed, it is to his abstemiousness that he is
chiefly indebted for the remarkable preservation of his elas¬
ticity, of his physical as well as mental vigor, and of his
health; this, too, in spite of a far heavier succession of mis¬
fortunes, national as well as domestic, than fall to the share
of most men. His predecessor on the throne, the semi¬
imbecile Emperor Ferdinand, was renowned for his drunken
habits, and it is no secret that the appalling fits of epilepsy
which wrecked his mind and rendered his abdication imper¬
ative were, in the most cases, the result of excessive indulg¬
ence in what are described as “the pleasures of the table.”

The insanity that made necessary the removal of the
late King Louis from the Bavarian throne, and that resulted
in his tragic death, was, according to the official diagnosis
of the medical authorities, superinduced by alcoholism, and
under the circumstances those who were his subjects may
rejoice that they are now governed by a regent who, in spite
of his deriving a large proportion of his revenue, official as
well as private, from the brewing and sale of beer, is not
only temperate himself, but has also inculcated this particu¬
lar virtue on his sons and grandchildren.

In Wurtemburg a young and brilliant cavalry officer who,
even when serving with his hussar regiment, was noted for
his reluctance to participate in the drinking bouts of his fel¬
low officers at mess, h^s taken the place of the gross, sensual,

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295

and semi-demented King Charles, who would have been
deposed over and over again by his disgusted lieges had it
not been for the care of his clever Russian wife, who practi¬
cally governed the country after he had become mentally
unbalanced through inebriety.

The Grand Duke of Baden succeeded to a brother who
was deposed for lunacy due to the same causes, while the
closing scenes of the long life of old King John of Saxony
were saddened for his relatives and friends by the perpetra¬
tion of a number of astounding freaks that could only be
attributed to an excessive indulgence in stimulants.

Those who have had the opportunity of glancing over
the illustrated and comic papers of the fifties may possibly
recall to mind the cartoons and caricatures which were
published, especially by Punch , at the time of the interna¬
tional congress held at Paris at the close of the Crimean
War. To Prussia was allowed no share or representation in
the proceedings on the ground that she was not entitled to
rank as one of the Great Powers of Europe, and the cartoons
represent the Prussian king, Frederick William IV, clamor¬
ing in vain for admission to the congress, in a state of mani¬
fest inebriety, with his crown cocked on one side of his
head, several champagne bottles under arm, his face inflamed
and his uniform unbuttoned, while the doorkeeper is urging
him to “go home” on the ground that he had been dining,
“not wisely, but too well.” Sad to relate, this was no over¬
drawn picture in so far as the habits of the Prussian sov¬
ereign of that day were concerned. His excesses at the
table were such that the most extraordinary scenes and inci¬
dents would ensue during the receptions and balls that fol¬
lowed the court dinners, the king being subject to all sorts
of drunken hallucinations, some of which were ludicrous and
others of exceedingly painful character.

Of Denmark it is merely necessary to repeat what has so
often been said, namely, that its court is a pattern for the
remainder of Europe in matters of temperance as well as in
every other respect, and it is impossible to overestimate the

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good achieved by the influence of the aged queen and king,
the latter presenting an agreeable contrast to his predeces¬
sor, whose court was such as to cause it to be subjected
throughout the latter part of his reign to something akin to
ostracism by the other crowned heads of Europe.

The late King Charles of Sweden was famous as a bon
vivanty and while not a drunkard, could by no means be re¬
garded as a temperate man, whereas the views of his succes¬
sor, King Oscar, are best shown by the significant fact that
he has permitted his queen to join the Salvation Army, and
his favorite son and namesake, Prince Oscar, to assume the
presidency of the temperance movement of Sweden and
Norway.

The young Czarina of Russia, with her strong, high-
principled mind, added to her cleverness and beauty, may be
relied upon to counteract any disposition that her husband
may have inherited from his ancestors in connection with a
taste for stimulants. During his sojourn of several months in
England prior to his marriage, however, he surprised those
with whom he was brought into contact by his very un-
Slavonic abstemiousness, Russians being noted for their
hard-drinking propensities.

King Charles of Roumania, like King Leopold of Belgi¬
um, is temperate in the extreme, being far too cautious a
man ever to permit his brain to become clouded by stimu¬
lants.

The King of Portugal, although he delights in convivial¬
ity and enjoys the reputation of being a good fellow in every
sense of the word, has never been known as a heavy
drinker.

The King of Spain, from his earliest infancy, has dis¬
played a pronounced aversion to the bottle, and has objected
to being brought up “ by hand,” as the saying is. It is to
be hoped that this ill-will toward the bottle may continue
throughout his life. Much apprehension need not be enter¬
tained on the subject, since the Bourbons have always been
more noted for their excesses in eating than in drinking.

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297

But the sovereign to whose influence the growth of tem¬
perance is due more than to any one else is assuredly Queen
Victoria, the doyenni of all the monarchs of the world. Her
father and her uncles, particularly those who immediately
preceded her on the throne, namely, King George IV and
King William IV, were typical “ six-bottle men,” and seldom
if ever went to bed sober, Carlton House, the residence of
King George, being the scene of some of the most infamous
drunken orgies of the present century. At the same time,
the British court was renowned for the many scandals by
which its atmosphere was tainted. No gentleman arose
sober from table, and no gentleman uttered a single phrase
without garnishing it with the most frightful and blood¬
curdling oaths. Queen Victoria was but a young girl of
barely eighteen when she succeeded to the crown; yet, in
spite of this and of the influences by which she had been
environed since her childhood, she quickly succeeded not
only in purifying the court, but also in inaugurating an
entirely different tone in society, the coarseness and drunk¬
enness which had flourished until then giving way to refine¬
ment and abstemiousness. She was aided in her task by her
blameless husband, the late Prince Consort, and since his
death his good work in this particular has been carried on
by his son, the Prince of Wales, to whom those interested
in the cause of temperance owe a far greater debt of grati¬
tude than most people would be willing to believe. For no
one is more intolerant of inebriety and of the vulgarity
which it invariably engenders than England’s future king.—
Life and Health.

SOME PERSONAL EXPERIENCES.

In an experience of nearly a quarter of a century in the
association, cure, and treatment of inebriates many strange
events have passed under my observation. Years ago the
views of disease which I urged were sharply ridiculed and
condemned. Clergymen and reformers were especially
severe in their criticisms. A clergyman of much promi-

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nence, and a most excellent man, thought it his duty
warn his people of the danger of believing that inebri<
was a disease and the bad influence of my preaching in t
direction. Some years later this clergyman came a lc
distance to consult me regarding the inebriety of his son.

A reformer and lecturer, who was for many years
severe critic of my work and writings, became an inet
ate and begged to be placed under my care. He reo
ered, but died from drink excess a year later. An incre
ing part of my daily work is consultation regarding t
capacity and incapacity of inebriates and moderate us<
of spirits. Many years ago a lady consulted me respecti
the marriage of her daughter to a young man of weal
from a good family, who drank to excess. He had promis
to abstain after marriage, and craved the privilege of usi
wine at the wedding, after which he would become a to;
abstainer. I advised against this marriage on these tern
and gave the mother a gloomy prediction of the future
such a case. A short time after the father of the youi
man consulted me in this same case, thinking that his s<
would recover by marriage. My advice against this w
taken, and within a year this young man married into anoth
family. He continued drinking, and died two years later
great wretchedness. His wife was left a comfortable fc
tune. The girl he wished to marry at first, whose moth
had consulted me, married a clergyman, and a few yea
later was left a widow in destitute circumstances, with tv
children. Both families are severe in personal denunciatioi
of my judgment, and believe that had the first marria^
taken place this man would have become an abstainer, ar
at least his wife would at his death have been left comfoi
able,— the same old story of what would have happene
that rises up to distress many good persons.

In reality the best judgment of the time and place
all that should be expected, and in the larger number <
cases this is the best wisdom and is followed by the be!
results. A W. C. T. U. society had gathered a sum (

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money to build a hall and reading-room, and a private
banker, who was a drinking man, held the money on deposit.
Some members objected to this and appealed to my judg¬
ment. I could only urge on general principles that this was
perilous. When the society was ready to build it was
found that this banker could only, pay a small part of the
money, as his property was involved. Severe recriminations
have followed, but the mistake was the failure to act on
sound common-sense principles.

In all these questions associated with inebriety there is a
common-sense view that must be the basis of all judgment.
A man who has pursued a line of conduct for years and
proposes to stop or change at once by the mere act of will
power, and then urges that you have full confidence in his
ability to do what he says he will, demands that which is
opposed to common sense. The restoration of inebriates is
a gospel of works; the reforms and revolutions we are all so
anxious to help on are also a matter of works. The faith
and confidence we expect others to have in our labors must
be based on realities and works that will* bear the tests of
time. The theory that inebriety is a disease and curable, if
it had been a mere opinion or guess work, would long ago
have been put aside. Reformatory efforts to build up a
correct public sentiment regarding the evils of the use of
spirits and other social perils, will never succeed unless
founded on great principles and supported by laws of
growth and evolution.

Two devoted women organized a W. C. T. U. in a New
England village in opposition to the best and leading
society. They gathered a few factory girls and began, con¬
scious of their final triumph and the reality of their work.
The criticisms and sneers and social ostracism of the first
two years only paved the way for great popularity, which
came at last by works and solid realities that rose above all
theory.

To the scientific man criticism and doubts, even to per¬
secution, have no perils or discouragements. If the facts
he urges are true they will only grow the stronger by

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Clinical Notes and Comments .

opposition, and if they are not true, he will be the first to
discover their error and put them aside. There can be no
fears of true work, real facts, and common-sense opinions.
Criticisms and denials of the reality of any facts or work
are very common and very cheap in the market. Anybody
can indulge in them, but the men or women who can rec¬
ognize the truth, and have the courage to urge and defend
it, are the real workers of the ages. The many great ques¬
tions concerning the drink problem and its associate evils
are unknown in the general world, and hence a wide differ¬
ence of personal opinion must exist. Men and women who
have made much study and observation of these topics, are
the least assertive, and most tolerant and quick to welcome
any new facts, based on study and experience, while those
who know least are the most dogmatic and positive. The
theorist who describes inebriety and its causes with startling
minuteness, and points out the exact remedies, and an¬
nounces that specifics have been found, and is able to
explain their action, is always the most ignorant, and liter¬
ally has no real knowledge of what he is talking about.
The person who knows all about these confusing questions
is always the one to be avoided, while the real student, who
possesses real knowledge, is so conscious of how little he
knows compared with the unknown, that he states his facts
modestly and as views that may change from a larger and
more complete knowledge.

Every year’s experience brings into greater prominence
the necessity of accurate, sociological, and scientific study
of all these problems, and the means of prevention and cure.
If the W. C. T. U. should through its large membership
gather facts on the various disputed points, and put them in
available form, it would be a recognized and valuable
advance. If the burning reformers who are so anxious to
help on the march of the race will become fact-gleaners
everywhere, they can do permanent work, the influence of
which will be felt far down the coming years. This age
wants facts , not opinions or theories.— Extract from a lecture
by Dr . Crothers.

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SOME STATISTICS OF TOBACCO, TEA, AND
CHAMPAGNE IN ENGLAND.

The great increase in the consumption of tobacco, es¬
pecially among growing lads, cannot fail to have its due
effect on the development of both mind and body. The net
revenue yielded last year by the tax on tobacco amounted to
fifty-two and a half millions of dollars, this being in excess
of the sum yielded from the same source during the preced¬
ing year by more than a million and a half. The excess is
mainly attributed by the chancellor of the exchequer to the
increase in the consumption of cigarettes. Another point
revealed by the budget is the increase in the consumption of
tea, ten million more pounds having been consumed during
the past than in the previous year. That we are not neces¬
sarily becoming a more temperate nation is shown by the
fact that in 1895 no less than 1,200,000 extra bottles of
champagne were drunk. As usual, with returning prosperity
the first rush is to the whisky-bottle and the decanter, and
the increase in the consumption of the lighter wines and of tea
does not redeem the outlook as regards the national health.
—Therapeutic Gazette .

TREATMENT OF ALCOHOLIC CIRRHOSIS OF
THE LIVER.

While the line of treatment to be pursued in cases of al¬
coholic cirrhosis of the liver are pretty much the same
whether the viscus is enlarged or diminished in size, the
prognosis is much less favorable under the latter than under
the former condition. The diet should consist essentially of
milk, not less than three quarts being given in the course of
the day in divided amounts. Alkaline waters in moderate
quantity may be permitted. If the milk is badly digested, to
each glassful may be added a tablespoonful of the following
solution:

IJ. Calcium chlorid, 15 grains.

Water, - - - 3 ounces.

Vol. XVIII.—46

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Clinical Notes and Comments .

Or, with each glass of milk a tablet of the following compo¬
sition should be taken :

IJ. Pancreatin, )

Pepsin, > aa - - 3 grains.

Sodium bicarbonate, )

When the ascites has disappeared and the digestive
functions are improved, in the course of from six weeks to
four or five months, the severity of the regimen may be
mitigated and white meats, green vegetables, and a small
amount of farinaceous food permitted, while alcohol in any
form, red meat, fat fish, and condiments are to be withheld.
When possible, the milk-cure may be conjoined with the
raisin-cure. Medicinally potassium iodid may be given in
doses of from to 30 grains, if necessary, for a period of
several months. This drug is especially useful if the liver is
fatty. When the disease is advanced iodism is to be guarded
against, as this condition is attended with an increased prob¬
ability of hemorrhage. If the enlarged liver is painful, and
congestive exacerbations occur, calomel is to be adminis¬
tered — either gr. i-6 or gr. 1-3 every morning for several
months, or, beginning with gr. 3-4 four times the first day,
administering gr. 1-5 four times a day for six days, then inter¬
mitting for fifteen days and then resuming as before. Mean¬
while, the mouth is to be carefully watched for signs of mer-
curialism. Local revulsion meets the same indications as
calomel. Vesication is to be avoided, as the kidneys are
rarely healthy. As a diuretic calomel may be employed in
doses of from gr. jss to gr. iij four times a day. A combi¬
nation of squill, potassium nitrate, and potassium acetate
may also be employed, or lithium carbonate with potassium
nitrate, or a combination of the powder and the extract of
squill. As a purgative gamboge may be employed, or
euonymin with extract of hyoscyamus, or a combination of
magnesia with flowers of sulphur. When, in spite of diet,
diuretics, and purgatives, the ascites does not diminish or
occasions dyspnoea, the fluid must be evacuated by punc¬
ture, repeated if need be. ( Gaz . Hebd. de MM. et de Chi -
rurgUy 1896, No. 28, p. 335 .)—Medical News.

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Clinical Notes and Comments .

303

ALCOHOLIC NEURITIS IN OLD AGE.

In a recent number of Brain Dr. Maude publishes a
brief account of a most interesting case. The patient, who
was a robust country gentleman of sporting habits and used
to an out-of-door life, had taken stimulants in considerable
excess for at least twenty years. Even eighteen years ago
no unusual daily allowance was half a gallon of beer, a bottle
of sherry, and eight or ten liqueur glasses of “neat ” whisky.
His favorite drink was beer, and even in the summer of
1894, although over seventy-five years of age, he would
often consume two quarts of beer, a bottle of sherry, and
half a bottle of whisky in a day. He had had no serious
illness, except broken bones from riding accidents and a
fractured humerus at the age of seventy-three from a fall
downstairs one evening after dinner. During the year 1894
his great muscular power became much impaired, and toward
the end of the year he began to complain of severe darting
pains in the left lower limb. A few weeks later the hands
and feet began to swell rather suddenly, the skin became
thin and glossy, while there were small echymoses over it.
A similar condition was present on the insteps of both feet,
while the calves and thighs were aedematous and the
muscles shrunken. The knee-jerk could not be elicited, and
the pupils were small and did not react to light. The heart
sounds were somewhat feeble, but they were regular and
there was no sign of dilatation. Without any previous
marked change in his symptoms he died suddenly after a
few minutes’ dyspnoea about two months after the onset of
.the symptoms. Dr. Maude considers the case to have been
one of peripheral neuritis, and directs attention to several
interesting points, such as the advanced age of the patient,
the excess of his alcoholic indulgence, and the absence of
mental change; the fact, also, that he was essentially a beer
drinker is interesting, with reference especially to the views
of the late Dr. James Ross as to the kind of alcoholic bever¬
age most likely to produce neuritis .—The Lancet , October
19, 1895.

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304

Clinical Notes and Comments .

HOMES FOR INEBRIATES ASSOCIATION.

This association is composed of eminent bishops, mem¬
bers of Parliament, and medical men, for the special purpose
of promoting the formation and growth of asylums for ine¬
briates in England. The following extracts of report for
1895 are worth a note:

The experience of another year has proved strongly con¬
firmatory of the presence of a diseased condition in many
inebriates, and of the fair prospect of a cure of the disease
of inebriety, especially if treated at an early stage of the
malady.

The Committee have now had a record of the results of
systematic treatment of inebriety, so satisfactory as to justify
them in the expression of the hope that efficient legislation
may ere long be enacted for the scientific treatment, for
purposes of cure, of inebriates of every rank and position in
life, and for the compulsory reception of such victims of this
disease as are too broken down in will power to apply of
their own accord for admission and detention.

The Committee are glad to know that two Government
Departmental Committees have been taking evidence on
the subject, from experts and others in a position to know
the truth, and that they have found a general concensus of
opinion in favor of legislation for the compulsory reception
and therapeutic detention of habitual drunkards.

INEBRIETY AND MODERATE DRINKING
AMONG ACTIVE WORKING RAILROAD MEN.

The Voice recently made an active canvass of the drink
question among railroad men. Twenty-five of the great
leading railways in the country answered a series of ques¬
tions through their managers. These roads employ 180,000
men.

Allowing the usual family of 5 to each employe, it fol¬
lows that these 25 managers in a measure control the desti¬
nies of 900,000 souls. Out of these 25 managers, every one

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Clinical Notes and Comments .

305

denounces habitual drinking among employes as making
them inefficient for work. Nineteen of these magnates for¬
bid the use of liquor by all employes while on duty; five
forbid it to trainmen only while on duty, and*one did not reply
to the query. Eighteen of these managers require total
abstinence on the part of their employes in their train ser¬
vice, and many require it in all branches. Moreover, these
25 men are unanimous in their declaration that they give
non-drinking men the preference, both in giving employ¬
ment and in the matter of promotion. The bogus personal-
liberty dogma is not recognized in a service where sober
men and clear heads are required.

THE VINO-KOLAFRA.

This preparation of the kola nuts has been used as
antidote for the poison of alcohol, and some authorities have
called it a specific. Recently, through the kindness of
Johnson & Johnson of New York, we have made a study of
its action in several cases of acute and chronic inebriety.
The plan was to discontiuue all spirits and give vino-kolajra
every two or three hours in two-ounce doses. After the
third or fourth dose the acute symptoms subsided and the
patient became easy, the stomach distress and demand for
spirits subsided. In two cases sleep followed, from which
the patient awoke rested. In two cases a marked change
occurred in the restlessness and excitement, and the effects
of alcohol seemed to be neutralized, the mind improved.
Its action was that of a diffusable stimulant, with the
narcotic tendency to relieve the irritation and psychical
suffering of such cases. There are many reasons for
believing that its greatest value is in replacing spirits, and
lessening the suffering from the withdrawal of the drugs.
In these cases this action was marked and almost a specific,
and in all probability it can be used with equal advantage in
other drug addictions. We shall report again on this drug,
and hope our readers will try it in all cases of inebriety for

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30 6

Clinical Notes and Comments .

the first few days after coming under treatment. It cer¬
tainly promises to be a most valuable remedy in the first
stages of the treatment of these drug diseases.

The Arethusa spring water has already won a place
among the great table and medicinal waters of the present
time.

Our attention has been called to Somatose f a nutrient in
powder form containing albumoses and other meat salts.
We have found it exceedingly valuable in anaemia and
wasting disease, and in degeneration from alcohol and other
drugs. Send to W. H. Schieffelin Co. for a box. Somatose
combined with cocoa and chocolate in the form of crackers
is very palatable.

The Hyde-Frank tin mineral water of Ballston Springs,
N. Y., is a bi-carbonate of soda water, of great value in
Bright’s disease, rheumatism, and various stomach troubles.

Taka-Diastase was mentioned as a remedy for all forms
of dyspepsia by mistake in the last number of the Journal.
In reality it is a remedy especially intended for cases where
starchy elements of food are not properly converted into
sugar. The well-known firm of Parke, Davis & Co., who
bring out this new compound, are the pioneer chemists who
are revolutionizing practical pharmacy in this country by
their new drugs of estimable value.

Jno. C. Lewis, M.D., West Bridgewater, Pa., says: “I
have used Celerina in my own case for insomnia. Among
all the hypnotic preparations and nerve tonics it stands justly
pre-eminent. Several persons are now using it and report
that no preparation has given such permanent and prompt
relief. In a general practice of more than half a century,
this is perhaps the first public testimony I have offered.
Celerina is the very best nerve tonic now offered to the pro¬
fession, and cannot be too highly recommended. To those
wanting a nerve stimulant it will be just the remedy.”

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Clinical Notes and Comments .

307

T. H. Lindeman, M.D., St. Louis, Mo., writes: “I have
used Nepenthe (Tilden’s) in the treatment of flux, cholera
infantum, and diarrhoea of children, and I find it an excel¬
lent remedy, and can recommend it to the profession. ,,

We publish in our advertising pages notice of the
Worcester Fire Pail Co., and believe it one of the most
practical and valuable of all hospital appliances. Send for a
circular.

Antikamnia is a very widely known drug, and has stood
the test of critical experience. It may be used with great
confidence in all neuralgiac, hysteric, and neuraesthenic
states. In drug addictions we have found it valuable and
free from all danger, and the least depressing of all medi¬
cines used to control pain.

“ The medical profession of the United States and other
English-speaking countries has long held the well-known
firm of Reed & Carnrick, manufacturing chemists, in high
esteem. Their name has been synonymous with honesty
and integrity; the conduct of their great business has been
such that no one could take exception to it. They have
been most careful to maintain and strengthen the traditional
dignity and conservatism of the profession. ,,

Protonuclein and Peptenzymc are two new remedies that
this firm are presenting to the profession, which are attract¬
ing great attention by their practical value in many diseases
of digestion. A small pamphlet on this subject prepared
by this firm is well worth reading. Send for a copy.

In Maltine with Hypophosphites the vehicle ceases to be
a mere vehicle. It is a highly concentrated and partially
predigested extract of the three cereals, wheat, oats, and
barley, and, therefore, a positive and valuable adjunct in the
treatment of every condition in which the hypophosphites
are indicated.

The Fellows' Syrup of Hypophosphites has been on the
market for years, and is always found valuable wherever

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308

Clinical Notes and Comments .

used. It is one of those remedies which become more
popular and attractive as its remedial power becomes known.
It is used both by medical men and the laity, and grows in
popularity every year.

Horsford Acid Phosphates , like the sentiment in the song,
goes on forever. Other drugs may come and go, but this
compound continues the same yesterday, to-day, and who
will deny that it may go on far down into the future.

Boehringer & Soehne manufacture a superior quality
Cocaine Muriate , and various standard chemicals, alkaloids,
such as atropine, codeine (pure, phosphate, sulphate, etc.),
chloral, eserine, resorcin, terpin, hydrate, etc., also quinine
sulphate. They are also manufacturers of the famous
Ferratine , an iron and food tonic, also Lactophenine , the
new antipyretic.

Arsenauro . The liquor auri et arsenii bromidii . This
is one of the best tonics we have used in the chronic degen¬
erations following the use of alcohol and opium. In two
typical cases the effects were very marked, in the rapid
improvement which followed its use. In theory it should
be very valuable; in our practice it has more than sustained
all expectations. We urge the extended use of this drug in
all cases of inebriety, not as a specific, but as an alterative
tonic that promises much for the future. We shall give
some results of a larger study in the next number.

Wheeler's Tissue Phosphates is a favorite remedy in
many cases of exhaustion, and should be given a trial in all
such cases.

Listerine is invaluable as an antiseptic on all occasions.

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THE

Quarterly Journal of Inebriety.

Subscription, $2.00 per year.

Vol. XVIII. OCTOBER, 1896. No. 4.

This Journal will not be responsible for the opinions of contributors, unless
indorsed by the Association.

THE USE OF COCAINE AND ACCIDENTS RESULT¬
ING FROM IT —CLINICAL CONCLUSIONS.*

By Dr. E. Delbosb.

Our aim being to legitimatize the judicious and correct em¬
ployment of cocaine, we shall take good care not to present
this substance as being absolutely inoffensive. There have
been cases of poisoning, and cases so serious that they have ter¬
minated fatally; but we believe that this toxicity has been
greatly exaggerated.

And first of all this habit of considering all unexpected
phenomena as being indicative of poisoning cannot be too
strongly inveighed against. It must be acknowledged that
the physiological properties of cocaine are not well known;
thev are even so little known that we do not yet know how
to administer it internally. Thus it happens that when this
medicament, employed under more or less favorable conditions,
is absorbed and manifests its normal properties by modifying,
although in a very slight degree, certain functions of the or¬
ganism, immediately a cry is raised of poisoning.

♦Continued from July number.

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310 Use of Cocaine and Accidents Resulting from it.

But, looking at it in this way, few substances would be ab¬
solutely inoffensive. How often does the administration of a
medicine not produce the effect expected of it? And if the un¬
expected should happen must we call it poisoning? Thus, a
common purgative administered under certain conditions may
produce vomiting, but no passage of fecal matter; in order to
be logical we should say that such a patient is sick as one is
sick who, from overeating, has a fit of indigestion, and is at¬
tacked by violent nausea. Even this is much more serious
than certain phenomena produced by cocaine and dignified by
the name of poisoning.

For example, a patient is analgesiated by the alkaloid, turns
pale on seeing the operator handle his instruments, his heart
beats faster, and these symptoms, due to simple emotion, are
looked upon as toxic and are so recorded. Medical litera¬
ture is full of such statements. If we wished to relate all the
observations recorded by the dentists, one volume would not
suffice. 1

For example, Dr. Roux, in the Revue Medicale, February,
1889, writes as follows: “ The number of fatal poisonings
by cocaine reached last October the respectable number of
126.” M. Roux, in reply to a letter of ours on the subject,
gave us the sources of his information. He acknowledged
having made a mistake. He should not have said 126 fatal
cases, but 126 cases, of which some were fatal; he did not
know the exact number of the latter. His conclusions were
drawn from a compilation made by Drs. Dumont and Berne.
Dr. Dumont, in his turn, was indebted chiefly to the works of
Mattison on cocaine.

We have read an analysis of this work in the Tribune Medi¬
cale of January, 1888. At the beginning of the article four
cases are made mention of; but, on reading the work carefully,
we have been able to find nothing more about them. In fact,
some observations are recorded in such vague terms that we
often cannot determine whether they ended happily or not.
How, then, can we discuss facts recorded with so little pre¬
cision? We shall content ourselves with our own statistics.

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Use of Cocaine and Accidents Resulting from it. 311

What makes us think that we possess the correct and al¬
most complete records of cocaine is that in a recent article by
Professor Lepine in the Semaine Medicale, May 22, 1889, we
have found few records of which we had not previous knowl¬
edge*

But before proceeding, we must confess something. It is
evident that in this table (the author here alludes to a table of
77 cases which lack of space prevents us from reproducing),
the poisonings have not been presented in their order of grav¬
ity, but according to the dose employed. We are obliged to
acknowledge that our records are not complete for a dose less
than 0.05. When, with the same dose of cocaine, several
cases presented the same symptoms, we recorded but a few such.
But starting from 0.05, the dose usually employed, we have
recorded, without exception, every case that came to our knowl¬
edge.

Let us first of all examine those poisonings due to a quan¬
tity of cocaine less than* 5 centigrams. In the first place, what
are we to think of those provoked by almost infinitesimal doses?
Can we seriously believe them to be due to intoxication? We
must then believe cocaine to be the most dangerous of the
alkaloids. We are inclined, therefore, to believe with Unkow-
sky and Hugenschmidt that emotion plays a prominent part
in the development of certain accidents.

The following record made by Hugenschmidt is a strik¬
ing proof of this theory. He was called upon to administer
cocaine to a woman 60 years of age, who had to undergo a pain¬
ful dental operation. She was very much excited and per¬
suaded that the medicament to be used was exceedingly dan¬
gerous. Under such conditions, Hugenschmidt refused to ad¬
minister cocaine, but, pressed by the woman to do so, he pre¬
tended to yield and injected ten drops of distilled water. In
less than thirty seconds the patient complained of terrible pains
in the head, rose quickly, made a few steps, and sank on a
lounge, crying, “ I am dying.” A syncope ensued lasting half
an hour.

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312 Use of Cocaine and Accidents Resulting from it.

Now suppose Dr. Hugenschmidt not to have injected dis¬
tilled water; these symptoms would have been credited to co¬
caine, and we should have a rather serious case of poisoning,
since there was syncope lasting half an hour. We are inclined
to believe that a great number of cases are attributed to a like
cause.

What, now, are the symptoms when the dose is less than
0.05? On consulting our table we find that the most common
are: pale face, cold sweat, vertigo, weakness, dry throat, em¬
barrassed respiration and syncope. But a simple emotion is
perfectly capable of producing all these. Besides, in confirma¬
tion of this hypothesis, we may remark that in many observa¬
tions the subjects were sickly, impressionable, nervous, or hys¬
terical.

We do not, however, bv any means refuse credence to all
these cases; even below 5 centigrams cocaine may have active
effects. But we refuse to attach any weight whatever to these
accidents, which are also of rare occurrence, since for one case
where disagreeable symptoms have shown themselves, we
could cite fifty where all went well. We believe rather in an
idiosyncrasy which, outside of all nervous heredity, renders
one patient more sensitive than another to the action of the
alkaloid. Cocaine, therefore, should be placed among those
substances for which there exists individual susceptibilities.

From this we conclude that a dose inferior to 0.05 may be
employed with impunity. The few accidents that may result
will be perhaps disagreeable, but never dangerous.

But may we use 1.10? Looking at our table, we see that
the administration of 0.05 has been fatal. Let us study this
case in detail. It is of capital importance for, if the death was
truly due to cocaine, the employment of this drug should be
prohibited. It was at the meeting of the Ophthalmological
Society of Paris, Oct. 2, 1888, that M. Abadie reported this
observation.

“ A woman 71 years old, for entropium, received in the
eyelid the contents of a Pravaz syringe, containing a solution of

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Use of Cocaine and Accidents Resulting from it. 813

5 p. c. cocaine. -At first no sensation; but scarcely was the
operation finished whan the patient staggered, lost conscious¬
ness, the face became livid, the lips blue, as in asphyxia. Ar¬
tificial respiration was used, two injections of ether, cafeine.
Respiration reestablished, patient uttered a few words, and
M. Abadie left, believing her to be saved. Next day he
learned that the patient had succumbed in the night, five hours
after the accident. No autopsy; but the daughter informed
him that three months previously her mother had fallen in the
same manner, and remained six hours unconscious.

This report gives rise to an exchange of observations be¬
tween the colleagues of M. Abadie. Gorecki did not believe
in intoxication, neither did Meyer, because the patient had the
face livid and the respiration stertorous, phenomena which do
not belong to cocaine poisoning, but rather to cerebral apoplexy,
when taken in connection with the age and previous history of
the patient.

Now do we recognize the effects of cocaine in this case?
Poisoning by this substance has never caused congestion of the
face. We need only look over our statistics to see that the
face is always of a corpse-like pallor. It is true that the face
might have been congested if the victim had had convulsions,
but she fell down unconscious with no convulsive movements.
This again obliges us to discredit cocaine poisoning, for in all
the observations we have been able to collect there is not a
single case in which death has not been preceded by convul¬
sions. Can we then place accidents exhibiting symptoms con¬
trary to those produced by cocaine to the credit of cocaine?
We rather support the opinion of M. Meyer, and attribute this
death to cerebral apoplexy.

Cocaine, then, cannot kill at 0.05, nay more, even in larger
doses as high as 0.10, it is not dangerous. Nevertheless, the
cases reported do present phenomena of a grave appearance.
Thus, we have some observations with convulsive movements,
but this symptom has been chiefly observed in nervous and
hysterical subjects, and cocaine is well calculated to cause ner-
Vol. XVIII —51

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314 Use of Cocaine and Accidents Resulting from it.

vous accidents in those who have these symptoms in the germ.
Besides, we certainly do not deny individual predispositions,
idiosyncrasies which manifest themselves in proportion to the
quantity of active substance used.

As to the other symptoms, some of them may be explained
in the same manner as the above ones. It is beyond doubt
that the state of superexcitation, the emotion inseparable from
the idea of the operation, is among timid subjects the origin
of certain troubles of the eyesight, of vertigo, and even of
syncope.

There may be cited in objection to our theory cases re¬
sembling that of Howel Way, who, as an experiment, injected
into himself one grain of cocaine, and was, as he himself re¬
ports, at a hair’s breadth from death. It seems easy to explain
these accidents on realizing the proprieties of cocaine. We
know that one of the chief effects of this substance, employed
in weak doses, is the exaltation of the sympathetic system,
with consecutive diminution of the caliber of the vessels *ander
the predominant action of the vaso-constrictor fibres. Hence,
anemia of the base of the encephalon, giving rise to vertigo and
troubles of the respiratory and circulatory systems. In pres¬
ence of these symptoms an emotion, which may well be taken
for a legitimate one, will seize upon the patient and make him
think, instinctively, and in spite of himself, of a real danger.
The effect of the emotion, added to the action of the cocaine,
will still further slow the cerebral circulation; the two phenom¬
ena will then react, the one on the other, and syncope will be
imminent. This we think was the case with Howel Way; and
many other cases may be explained in the same manner.

These phenomena, which at first sight appear to be of ex¬
ceptional gravity, are not to be feared. To prove this, it is
enough to make the patient inhale two or three drops of nitrite
of amyl to bring back the cerebral circulation to its normal
state, and make every sign of syncope disappear immediately.
This was the case with Howard Way and with many of pa¬
tients, as is proved by numerous observations. We see, then,

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Use of Cocaine and Accidents Resulting from it. 315

that 0.10 centigrams of cocaine give rise to symptoms more
frightening than dangerous.

Let us now study the poisonings which have followed doses
of from 0.10 to 0.20 centigrams. Here again we find ourselves
in the presence of accidents at first sight of very dangerous
character, but this gravity is more apparent than real. Two
or three drops of nitrite of amyl generally cause the symptoms
to disappear.

We must, however, call attention to a new phenomenon,
little dangerous in itself, but interesting to note because it in¬
dicates a more energetic action of the drug on the system. We
allude to the cerebral excitation. A good example of this has
been reported by M. Reclus, and runs thus:

A man aged 40, very nervous, impressionable, came to be
operated upon for a lipoma in the shoulder. He dreaded the
operation, the result of which he feared. The field of opera¬
tion was anesthetized with 15 centigrams of cocaine. The
operation was begun, the excitement of the patient increased,
he began to weep, then got mad with himself for doing so, and
was seized with fits of fury, followed by maudlin ones. Final¬
ly there was extraordinary loquacity, little in harmony with
his naturally cold and reserved character. These symptoms
lasted three hours.

Regarding this case, it may be said that it is extremely an¬
noying to a patient that he should blurt out unwittingly mat¬
ters of which he would be very reticent when in his normal
condition. But this is not a sufficient reason for us to deprive
ourselves of the advantages offered to us by cocaine. Are we
not often compelled to search the past life of our patients in
order to arrive at our conclusions? Besides anesthetics in gen¬
eral and chloroform in particular are subject to the same re¬
proach. How often do we see patients under the influence
of chloroform recount episodes in their lives, and enter into the
most private details? Consequently this phenomenon of cer¬
ebral excitation must not be regarded as an obstacle to the use
of cocaine.

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316 Use of Cocaine and Accidents Resulting from it.

What must make us more circumspect are the convulsions
which have occurred with doses less than 0.20. This is an in¬
dication that cocaine has not contented itself with exciting the
excito-motor centers, but that it is exercising a truly toxic ac¬
tion on those centers. Happily, convulsions are far from being
the rule. In the two observations we have made, in the first
case the cocaine was injected into a region very rich in blood¬
vessels, for hemorrhoids; in the second a highly concentrated so¬
lution was used. Thus, in both cases, there was essentially
rapid absorption, and if we may credit our experience, this
is one of the conditions most favorable to the exhibition of
convulsive symptoms. We conclude, therefore, that cocaine
may be employed in doses of 20 centigrams; however, we shall
not recommend this dose in view of the phenomena we have
mentioned. It is true that we could easily cite numbers of
cases reported by M. Reclus when 20 centigrams have produced
no evil symptoms, not even paleness of face.

But beyond this dose we think that the greatest care should
be taken in the employment of cocaine. Accidents are multi¬
plied, the symptoms become more and more grave, and although
we reach the enormous quantity of 0.75 before finding the first
case of death, yet we believe that 0.20 should not be passed.

We shall not discuss the cases of death we have been able
to collect, but shall content ourselves with citing them, with
a few details.

M. Sims, in the Medical Hews, July 11, 1888, reports the
following case: “ A man 29 years of age was injected in the
urethra with one drachm (nearly 4 grains) of a solution of co¬
caine at 20 p. c. Hardly was the syringe withdrawn than the
patient began to be delirious. The eyes contracted, the pupils
dilated, he foamed at the mouth, respiration nearly ceased, and
the whole body was shaken by violent convulsions, which in¬
creased in violence. Respiration became more and more fee¬
ble, and the patient died twenty minutes after the operation.
At the autopsy the lungs were found normal, but greatly hy-
peremiated, heart healthy (right ventricle empty, left filled

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Use of Cocaine and Accidents Resulting from it . 317

with post mortem clots). Abdominal viscera and brain also
greatly congested. Mucous membrane of urethra healthy.

The case of Professor Kolomin is too well known for us to
enter into details. Cocaine employed for itching of rectum.
Injection into rectum of 24 grains. Twenty or thirty minutes
afterwards symptoms of poisoning. Loss of consciousness,
violent epileptiform convulsions, cessation of respiration.
Ether, nitrite of amyl, artificial respiration, bathing with ir¬
ritating substances, all useless; death in three hours.

Another case is reported in the Bulletin Medical of Febru¬
ary 24, 1889.

A house surgeon of University College Hospital had pre¬
scribed 3 gr. 25 of cocaine, which he intended himself to in¬
ject into the bladder of a man aged 30, suffering from acute
cystitis. He neglected to indicate on the prescription how it
was to be employed, and the druggist put it up as a potion. The
patient swallowed it. At first there were no symptoms, but at
the end of half an hour convulsions set in and the patient died.

Finally, the latest case was published by M. Montalti in
the Italian Joumal Lo Sperimentali.

This case is of medico-legal interest, and is that of a woman
who swallowed by mistake 5 grammes of a solution of 30 p. c.
chlorhydrate of cocaine, that is, 1.50 of the alkaloid. Fifteen
minutes after the drug was swallowed, the patient complained
of constriction of the throat, and was seized with an intense de¬
sire to vomit, without being able to do so. At the same time
the sight was affected, the pupils dilated, the lips became cya¬
notic, pulse thready, convulsions ensued, and death. At the
autopsy a small cavity was found in the right lung; the heart
was slightly fatty. The brain, meninges, and abdominal vis¬
cera were congested. Death, according to the verdict returned
in accordance with the expert testimony, was considered as the
result of poisoning by cocaine.

These are, in short, the only causes of death we have been
able to find in the authorities, for we refuse to recognize the
action of cocaine in the observation published by M. Abadie.

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318 Use of Cocaine and Accidents Resulting from it.

We see that a fatal termination is, on the whole, of rare oc¬
currence. If we were to examine the records of chloroform
we should find the mortality table very much higher. Besides,
cocaine is fatal only in fairly large doses. We must also re¬
mark that the evolution of the phenomena depends much on the
administration of the drug. Thus, in the observation recorded
by M. Montalti, cocaine was taken internally, and absorbed by
the stomach; we think that half the dose, administered subcu¬
taneously, would have been fatal. In fact, all depends on
the rapidity with which it is absorbed. Our experiments -with
rabbits demonstrated this fact perfectly. We had fatal re¬
sults on injecting into the peritoneum 20 centigrams per kilo,
of the animal; and 5 centigrams injected into the auricular
vein produced a like result. The size of the dose is then some¬
what relative, and we might administer with impunity to the
stomach a dose that we dare not inject into the cellular tissue.

This distinction is not a useless one, but deserves to be taken
into consideration; for a vein may very easily be pricked by the
needle, and the solution of cocaine be introduced into the cir¬
culation. This must sometimes have happened; and when in
the absence of all predisposition a minimum dose of the active
substance gives rise to phenomena of exceptional gravity, we
should be certainly disposed to believe that the solution had
been injected into a vein.

But how to guard against such accidents? This is an easy
matter. We need only conform to the method of operation em¬
ployed by M. Reclus as published by him, and his pupil, Isch
Wall, in the Surgical Review of Feb. 10, 1889. This method
consists in pressing the piston of the syringe as the needle sinks
into the tissues. We may perhaps pierce a vein, and introduce a
drop of the liquid into the caliber of the vein, but the rest of
the solution will certainly be injected into the cellular tissue.
We thus avoid introducing the cocaine directly into the circu¬
lation and putting it in practically immediate contact with the
nervous centers.

The too rapid absorption of this substance presents grave

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Use of Cocaine and^Accidents Resulting from it . 319

objections to some writers. Such is the opinion of Professor
Wolfler of Groz. Judging from his own statistics, he found
that it was possible to inject into the extremities a dose a third
greater than into the face. He appears to consider as possible
that cocaine introduced in the neighborhood of the brain may
reach it in a more immediate manner (by the lymphatic ducts)
than by the general circulation.

To avoid as far as possible this too rapid absorption, we must
avoid using concentrated solutions. Nothing but good effects
will come of so doing.

We know that cocaine produces analgesia by acting directly
on the sensory nerve cells; the more attenuated the solution,
the more the contact of the liquid with the cells will be mul¬
tiplied, and yet the total dose of cocaine will be weaker. The
2 p. c. solution seems to us the most desirable. Now, as we
have seen, we may use almost with impunity 20 centigrams, so
we may inject 10 cubic centimeters of our solution. And what
operatorv field can we not analgesiate with the contents of 10
Pravaz syringes?

Besides, we think this dose will be rarely necessary, and it
would be more prudent not to have recourse to it if we have
to do with nervous, anemic, or hysterical patients. If, on ac¬
count of a peculiar predisposition, accidents should happen, we
should inject ether, or, preferably, make the patient inhale two
or three drops of nitrite of amyl. In most cases the patient
will revive immediately, and recovery will be maintained by
cafeine. Should convulsions occur, give chloral. Chloro¬
form and ether are also recommended.

CONCLUSIONS.

Our experiments have confirmed the generally received
opinion, that cocaine is less toxic to animals than to man.

In spite of the most minute investigations, we have suc¬
ceeded in finding in medical literature only four cases of fatal
poisoning, and it is worthy of note that in these cases the quan¬
tity of active substance was always very considerable (0.75;
1.20; 1.20; 1.50).

With a dose of 0,20 by injection and in spite of the ap¬
parent gravity of the symptoms, the danger of death has never
been real.

We may then use this dose of 0.20, though it will rarely
be necessary, for with 0.10 of a 2 p. c. solution, the operatory
field anesthetized will be an extensive one.

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320

Dipsomania as a Defense for Crime .

DIPSOMANIA AS A DEFENSE FOE CRIME.

By James G. Kiernan, M.D.,

Foreign Associate Member French Medico-Psychological Association ; Fel¬
low of the Chicago Academy of Medicine ; Lecturer on Forensic
Psychiatry, Kent College of Law ; Professor of Mental
Diseases, Milwaukee Medical College.

Dr. J. P. Gray testified some years ago that 1 “ ‘Klepto¬
mania ’ is a word used to express thieving; there is no such in¬
sanity. ‘ Dipsomania/ I call it drunkenness; but I do not call
it insanity at all. Pyromania, incendiarism, a crime. All
these terms are makeshifts to secure from punishment for
crime.”

This demagogic evidence at the time represented neither
American clinical nor forensic psychiatry. Dr. W. W. God¬
ding, 2 a pupil of the Ray-Brigham school of American alienists,
commenting on this a priori cant, feelingly voiced the vast ma¬
jority of American and European alienists when he remarked:
“We cannot deny that the old masters were as keen-sighted
observers as ourselves. I dislike to hear drunkenness called
dipsomania, as I so often do; but I do not therefore say that
dipsomania is only drunkenness. It might improve my stand¬
ing with the legal fraternity if I should pronounce kleptomania
only another name for stealing; but my personal observation
convinces me that the insane have sometimes a disposition to
steal, which is a direct result of their disease, and for which
they are no more accountable than the puerperal maniac is for
her oaths.”

Judge Doe, of the New Hampshire Supreme Court, af¬
firmed a similar doctrine to that of Dr. Godding in the case of

1 Trial of Guiteau, Part II, p. 1674.

2 Two Hard Cases.

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Dipsomania as a Defense for Crime .

321

the State vs. Pike. The prisoner being indicted for the mur¬
der of one Brown, his counsel claimed that he was “ irrespon¬
sible by reason of a species of insanity called dipsomania.”
The lower court instructed the jury that “ if they found that
the prisoner killed Brown in a manner that would be criminal
and unlawful if he was sane, their verdict should be ‘ Not guilty
by reason of insanity/ if the killing was the offspring or pro¬
duct of mental disease in the defendant; that neither delusion,
nor knowledge of right and wrong, nor design or cunning in
planning and executing the killing and escaping or avoiding
detection, nor ability to recognize acquaintances or to labor or
transact business or manage affairs, is, as a matter of law, a test
of mental disease; but that all symptoms and all tests of mental
disease are purely matters of fact to be determined by the jury;
that whether there is such a mental disease as dipsomania, and
whether defendant had that disease, and whether the killing
of Brown was the product of such disease, were questions of fact
for the jury.” This instruction Judge Doe, in a decision re¬
plete with lucid grace of diction, clear logic, and scientific pre¬
cision, affirmed. 1

This plea was practically a successful one in the case of the
People vs. O’Brien, recently tried in Chicago. The chief
forensic points involved, and the general history of the case so
far as the defense of dipsomania is concerned, are excellently
summed up in the following hypothetical case:

“-Take a man whose mother was considered insane by her
son-in-law and grandson; whose father was a periodical drunk¬
ard; whose sister was insane, and was an inmate of an insane
hospital; whose other sister was peculiar, and, in the language
of a layman, a ‘ little off ’; whose maternal aunt is peculiar, and
considered by at least two of her relatives insane; whose ma¬
ternal first cousin is an idiot; and whose nephew has periods of
seeming unconsciousness.

“ Assume that this man when sixteen years old worked all
night without necessity, and that, when asked in the morning

1 Lawson's Criminal Defenses Insanity and Drunkenness.

Vol. XVIII—52

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Dipsomania as a Defense for Crime .

why he did this, was apparently unable to give either a coherent
account of what he did or why he did it. That in mid-winter,
when he was about sixteen years of age, he caused the machine
knives to be ground to cut grass, although there was no grass to
be cut; that on another occasion he ordered cows driven out
of an orchard lest they eat the apples, when there were no ap¬
ples there and snow was on the ground. That this man, now
at the age of about 38 years, for a known period of six years
immediately prior to the present time has had brief periods
when he became morose, restless, gloomy, and absent-minded,
and the expression of his eyes and face changed; that then fol¬
low violent drinking spells, lasting from four to ten days; that
he then drinks intoxicating liquor, with or without company,
in great quantities. During these drinking spells he is suspi¬
cious, extremely quarrelsome, boisterous, rough, and coarse in
manner, and does not discriminate in his violence between
friend and foe. That these periods terminate in prostrating
sickness; that on recovering from these drinking spells he is
pale and looks as though he had passed through a fit of sick¬
ness; that between these drinking spells there are irregular in¬
tervals of from four to six weeks when he is quiet in manner,
neither profane nor vulgar in speech, attentive to his saloon
business, and will often refuse intoxicating liquors; that just
precedent to, during, and immediately after his drinking
spells, his manner is in such marked contrast with the sober
periods that he has been thought to be insane and crazy by
several persons well acquainted with him. That his conduct
during these drinking spells is marked by strange extrava¬
gances. On one occasion he took a bear in a buggy for a drive.
On another occasion, on Christmas day, in one of his saloons,
then well patronized, he ordered the customers and bar-tender
out and locked the place up, and was seemingly unable to give
any good reason therefor. On another occasion he shot at a
colored man twice, in order, as he stated to the bystanders, “ to
show them how to kill a nigger.” On another occasion he
wished to erect a tank in the back yard and to hire a high

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Dipsomania as a Defense for Crime.

323

diver to dive off the adjacent building. That, about seven
years ago he became acquainted with a married woman who had
left her husband in California and was visiting in Chicago,
and from that time until about the month of May, 1895, he
lived with said woman in open adultery, and in said May (while
in one of said drinking spells) went with her to the city of Mil¬
waukee, where he was married to her by a justice of the peace;
that from that time until November 9th, with the exception of a
short interval, he lived with her as his wife; that on or about
said November 9th she left him, and did not again live with
him; that during the month of September, for a period of about
ten days, he drank excessively and had an attack in which he
was found wandering dazed about the hall of a hotel between 2
and 3 o’clock in the morning; that at the end thereof he re¬
mained sober, attending to his usual vocation as a saloonkeeper
until on or about November 9th, when one of his drinking spells
began, continuing until his arrest on November 19, 1895; that
during Thursday, Friday, Saturday, Sunday, and Monday
night, he was very restless and unable to sleep; that frequently
during these times he would go about his room with a frightened
look, and try the doors and windows, apparently to see that they
were locked and fastened, and while so doing would carry a re¬
volver in his hand, and, during the time that he was lying in
bed, constantly kept said revolver within his reach. That he,
some hours before the homicide, drank much intoxicating
liquor; that about 1 o’clock of the day of the homicide, at a
messenger service he asked for a messenger boy, and sent a
note to his wife—the boy failed to find her, and did not de¬
liver the message; that still later he sent another note, which
was not delivered; that afterwards, at his saloon, he drank more
liquor; that at or about 4 o’clock of said day he left his saloon
and went to where his wife then was with her sister, and rang the
bell of the flat adjacent to the door of the flat where his wife
was, whereupon his wife, accompanied by her sister, went to
the door of their apartments, opened it and said, “ Hello,
Brother,” and he replied, “ Don’t touch me.” That he had his

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Dipsomania as a Defense for Crime .

hand on his right overcoat pocket; that his wife went ahead
and he followed her to the front parlor; that she said, “ Here
are those keys;” that he said, “ When did you stay with that

white-livered-? ” that she replied, “ I never did;”

that he then said, “ Tell me or I will kill you;” that she said,
“ I never did;” that then two shots were heard, when the sister
ran down to the street crying for help, whereupon certain per¬
sons from the street visited said parlor and found the wife lying
dead from the effects of two pistol wounds; that one of the win¬
dows in the room was broken apparently by the revolver, from
which the said fatal shots were fired, joeing thrown through it;
that he, after said homicide, went down the back stairs, through
the alley, to the rear of his saloon, and drank liquor; that he
was in his saloon when the policeman entered it and said “ We
want you,” and at the same time the officer placed his hand
upon him and he replied, “ What do you want me for? ” and the
policeman replied, “ I guess you know.” That he was then
taken without resistance in a patrol wagon to a neighboring
police station; that when received at the police station he was
searched and some articles of personal property taken from him,
among them a diamond pin; that when that was removed he
said to the officer in charge, “ It is a valuable pin—take good
care of it—it is worth $150.” That when asked, “ Where is
the gun you used? ” he replied, “ I have used no gun.” That
then he asked to wash himself and was shown to the wash-room,
where he washed his face and hands; that after doing so he
looked at himself in the mirror and while so doing stroked his
moustache. On the following morning, on his way to the in¬
quest, he asked where he was being taken, and stated to the
officer in charge that he wanted a continuance.

This evidence was admitted by Drs. Harriet 0. B. Alexan¬
der, H. M. Bannister, J. A. Benson, H. Moyer, J. C. Spray,
and myself, to be sufficient to establish the existence of dipso¬
mania. This psychosis was defined by all these physicians as
a periodical insanity, characterized by an irresistible craving
for alcohol or narcotics during certain periods, preceded and

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Dipsomania as a Defense for Crime . 325

followed by mental change in the individual affected. These
periods are intermingled with periods of sobriety. The alco¬
holic element was regarded by all as a mere manifestation de¬
termined at the outset of the periods. The victim of dipso¬
mania, in the opinion of all, would be insane during the drink¬
ing periods even if alcohol were not used. The position of
the defense on the status of dipsomania in nosology was essen¬
tially that of Krafft-Ebing, Ritti, Spitzka, Kraepelin, and
Schuele. The demarcation made by the experts for the de¬
fense between dipsomania and drunkenness was essentially that
of Lagrain, 1 thus given recently:

An alcoholic patient becomes insane because he drinks; a
dipsomaniac is insane before he commences to drink. Dipso¬
mania may be complicated by alcoholic symptoms, but alcohol-:
ism never leads to dipsomania. Alcoholism is an intoxication
which has as its cause alcohol; dipsomania has its cause in a de¬
fective mental condition, and alcohol is but a secondary fac¬
tor, which may be replaced by any other poison, leaving to the
syndrome all its psychological characters. Dipsomania pro¬
ceeds in paroxysmal attacks, and the appetite for strong drink
is absent during the intervals between the attacks. Alcohol¬
ism has no definite course—its development depends directly
upon the more or less considerable or prolonged consumption
of alcohol.

The hypothetical case, it should here be stated, included,
in accordance with the usfiiat system of Judge Russel M. Wing,
the chief counsel for the defense, just sufficient evidence to
justify the diagnosis of the mental state, of the amount of will
power, and of the specific psychosis. The case as presented to
the jury contained other factors less incriminatory to the ac¬
cused and other evidence more strongly demonstrating defect¬
ive heredity and dipsomania. The State pursued the opposite
policy: all evidence implying insanity was omitted from its hy¬
pothetical case; it presented also a mutilated copy of the hypo¬
thetical case of the defense to its experts. With two excep-

1 Tuke’s Psychological Dictionary.

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326

Dipsomania as a Defense for Crime .

tions, the experts for the defense just named were not sub¬
jected to much cross-examination. Drs. Archibald Church,
Sanger Brown, and Richard Dewey appeared for the State.
They answered that the subject of the hypothetical case of the
State was sane, as every expert for the defense would have done.
They also stated that the hypothetical case of the defense had
been presented to them and that the subject of it was sane. On
cross-examination, Dr. Church gave the same symptoms of dip¬
somania as those presented by the hypothetical case of the de¬
fense, whereupon it was presented to him in its entirety. To
it, Dr. Church answered that the person of that hypothetical
case was insane with the type of insanity called dipsomania;
that his knowledge of right and wrong was doubtful, and that
he was the victim of an irresistible impulse. Drs. Sanger,
Brown, and Dewey substantially agreed with Dr. Church on
cross-examination. The position of all three as to the noso¬
logical status of dipsomania was identical with that of the ex¬
perts for the defense. The position of Drs. Dewey and Brown
as to the individual of the hypothetical case of the defense was
less emphatically expressed, but was practically identical with
that of Dr. Church; the results of whose cross-examination,
naturally under the circumstances, strongly influenced the jury.
No examination of the accused was made by the experts on
either side. The jury was left to decide as to the validity of
the two hypothetical cases. On the first ballot the jury stood
six for hanging to six for acquittal hip the ground of insanity;
on the second ballot five for hanging*to seven for acquittal on
the ground of insanity; the third ballot resulted in a vote of
eight for acquittal on the ground of insanity. The jury then
agreed on a verdict acquitting the accused on the ground of in¬
sanity, conditional on the Court committing the accused to an
insane hospital as a still dangerous lunatic. The Court de¬
clined to assume such powers, although permitted to do so by
the Illinois criminal code. The jury then attempted to find
the accused guilty of manslaughter so that he could reach an
insane hospital through a penitentiary. Four, however, still

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Dipsomania as a Defense for Crime .

327

sturdily voted for acquittal on the ground of insanity. The
jury was then discharged, unable to agree.

The jury was clearly convinced that dipsomania was a well-
defined form of insanity, and that the subject of it was so dan¬
gerous as to require permanent insane-hospital treatment. As
there was a “ hanging ” epidemic among juries just precedent
to this trial, it must be obvious that even under disadvantage¬
ous circumstances the seemingly dangerous defense of dipso¬
mania can be successfully made scientifically before an intelli¬
gent jury. Furthermore, the case shows that the pure hypo¬
thetical method of presenting evidence is far more just and
clear to a jury than when combined with the fact of examina¬
tion. Examination of an Reused person often is a wild ab¬
surdity unless the physicians have the clinical history. In
court the clinical history cannot be used, as it is practically
hearsay evidence. The jury is hence confused, since a con¬
scientious expert, used to legal procedures, will, in accordance
with his oath, exclude all but the results of his examination,
while the omniscient professional swearer will, in defiance of
all laws of evidence, testify to the results of hearsay as facts
resultant on examination. Fact witnesses and opinion wit¬
nesses should hence, in the interests of justice, be separated.
This the Chicago Academy of Medicine, the Chicago Medico-
Legal, Pathological, and Medical Societies tried to do by a bill
presented to the last Illinois Legislature. This bill, as final¬
ly passed, was so emasculated in the interest of certain omnis¬
cient medical politicians, the vampires of the courts, as to de¬
stroy its essential features and convert it into a new piece of
patronage machinery for judges.

I have not dwelt on the time-dishonored mob-law right-
and-wrong test, since it, under the decision in the case of Hopps
vs. The People, can only be used by trick and device of the
State’s attorney in Illinois.

Certain clinical data are lacking in the case which, from the
psychiatric standpoint are of especial interest. The aimless
insane performances during puberty suggest that cerebral au-

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328

Dipsomania as a Defense for Crime.

tomatism, which occurs in periodical types and affiliates these
to epileptic mental manifestations. It would be of interest to
know whether these performances passed at a later date, as
seems probable, into the rather suggestive acts of the “ drink¬
ing spells/’ and hence were an expression of a degenerative
defect which would be accentuated into irregular periodicity
after the age of twenty-five (the expiration of puberty), but
masked by alcohol. It has been claimed by Lasegue and others
that dipsomaniacs never manifest the symptoms of alcoholism.
This clinical criterion, as Legrain points out, is erroneous, since
many cases are on record where dipsomaniacs, even if their
attacks did not last a long time, showed symptoms of alcoholic
poisoning—excitement, tremor, delusions, nightmares, hallu¬
cinations, etc. That at the expiration of some of the “ drink¬
ing spells,” alcoholic mental states were present, seems clear
from the hypothetical case above cited, which also suggests that
the individual at the time of the homicide was in a most foren-
sically dubious alcoholic mental state, which, according to tes¬
timony of those present at the coroner’s inquest, lasted even
till then, days after. This testimony was omitted from the hy¬
pothetical case of the defense, intentionally, on the system al¬
ready described.

Identity of dipsomania and voluntary drunkenness was
claimed by the State, but this claim was upset by its own ex¬
perts. Dr. Sanger Brown, for example, took the position that
the voluntary drunkard is a sane man who drinks, while the
dipsomaniac is an insane man who drinks.

Dr. Harriet C. B. Alexander, an expert for the defense,
took the position, on cross-examination, that even during the
sober period the legal responsibility of the dipsomaniac was
dubious, and in the event of crime, the burden of proof of san¬
ity rested upon the State. This position, from the ordinary
legal standpoint of responsibility, is essentially sound. It is in
full accord with that recent decision of Judge Harlan of the
United States Supreme Court, which wiped out of existence
the demagogic decisions of the State Supreme Courts, which

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Dipsomania as a Defense for Crime . 329

have held that the prisoner must prove his insanity beyond a
reasonable doubt—decisions inconsistent with abstract justice
and anarchically inconsistent with that fundamental principle
of the criminal law of English-speaking countries, that every
one must be presumed to be innocent until proven guilty.

The State’s attorney cross-examined Dr. Alexander and
myself as to the forensic bearing of the language used at the
time of the homicide on the question of will-power and pre¬
meditation. The answer was that taken alone it was purely
negative in value, and taken in conjunction with the other fac¬
tors of the hypothetical case it had no significance; corrobor¬
ated by other facts bearing on the existence of will-power, it
might be of value. This position was based on the fact that
delusional threats and suspicions are often uttered during al¬
coholic, post-periodic, and epileptic mental states of which the
utterer has, at the best, but a dazed consciousness. The answer
was further based on the broad scientific principle that intelli¬
gent acts do not legally or medically offset distinct evidence of
insanity. Dr. Alexander was cross-examined most at length,
and myself next, although I could hardly call it cross-examina¬
tion. The policy of the State in this particular was due to the
sensible plan of avoiding errors in the record.

The difficulty encountered by the jury in their disposal of
the case must be felt by every thinking alienist. Some act em¬
bodying a modification of the English “ commitment pending
Her Majesty’s pleasure,” suitable to other English-speaking
countries, seems desirable. Another desideratum in the inter¬
ests of justice is a modification of State statutes which put a
premium on judicial murder by paying fees for conviction to
State’s attorneys.

Vol. XVIII—53

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330

Intoxication and Insanity.

INTOXICATION AND INSANITY.
/

By J. T. Searcy, M.D., Tuscaloosa, Ala.

Superintendent Brice Insane Hospital.

I will be glad to limit the meaning of the word intoxication
in this paper to the injurious effects on the cerebrum of toxic
agents present in the circulation. Toxic agents in the blood,
of course, have their chemic effects upon other structures, but
in the ordinary interpretation of the word the symptoms of
intoxication are those that belong to the brain. I will use
the word in that sense.

This organ is exceedingly sensitive to the action of certain
agents; so much so, in certain instances, that it seems to be the
only organ affected, or affected so far in advance of others
that their disturbance is not appreciated. The exceedingly
soft colloid character of the functionating central parts of its
nerve cells and fibers render them the most sensitive of all the
structures of the body to some agents; and their excessively
rapid functional motion is most delicately disturbed.

The nervous system, indeed, the whole body, may be di¬
vided into sensating and non-sensating structure. This is
only a fact in a comparative sense, because there are no defined
limits of the property of sensibility anywhere in the living
world. The broad generalization is commonly admitted, that
all living structures are more or less sensitive. In biology
there is an advance of grade in this property as we ascend in
the classification of species. Within the body of man the
property is more decided and distinct in some organs and parts
than in others. The nerve centers particularly have it as
their function, and, among them, it improves in delicacy and
distinctness untif we reach the cerebrum, where its most re¬
fined excellence is called consciousness. In man, so “ central-

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Intoxication and Insanity .

331

ized ” is the faculty that all conscious action may be said to
be cerebral. Sensibility in the human being is carried to
such a degree of centralization that the cerebrum is practically
the only sensorium. It is the organ of all “ feeling/” the
physiologic ego . The recognition of this as a physiologic fact
will explain many phenomena of the brainy in that of intoxi¬
cation it gives ready explanation to many of the symptoms
produced.

In intoxication the conscious feeling of the man is affected
and subjectively interests him most. His “ feelings ” are
altered, and he is concerned favorably or unfavorably as he
is comforted or discomforted.

In addition to being physiologically the conscious organ,
the brain is also the organ that adjusts the entirety we call
“ the man ” to his environment. The other nerve centers
have also adjustment as their function, but they adjust the
organs of the body internally to each other. The brain ad¬
justs externally.

The comparative excellence of structure and function of
one man’s brain makes him excellent in his external activities,
and the comparative weakness or defectiveness of another
man’s makes him less excellent or competent. We judge of
the integrity and functional capacity of this organ by the
emissions it makes, which in the aggregate go to make up the
exhibitions of the man’s intellectual capacity and constitute
what we call his conduct and character.

We judge, therefore, of the effect of a toxin and of the
degree of intoxication by the man’s recital of his own “ subjec¬
tive ” feelings; and we judge “ objectively ” by the “ symp¬
toms ” shown in his brain’s emissions. The symptoms of
intoxication have been discussed in medicine since medicine
first began. Because it relates seriously to the transcendently
most important organ in the body, it is a live question.

There are a great many agents that act intoxicatingly.
Some enter the circulation from within the body, are pro¬
duced there; others are introduced from without.

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Intoxication and Insanity .

We hear much said now-a-days about auto intoxication , by
which is meant the intoxication that is produced by toxins
produced within the body. The unqualified word intoxication
popularly means the series of symptoms produced by alcohol,
or some other such agent, introduced from without.

The word insanity is more properly a popular or a legal
term than a medical one, which fact occasions the trouble often
found by doctors in giving a medical definition to it for legal
use. Legally, insanity relates to conduct alone, and not es¬
pecially to the brain condition that produces it. The gradu¬
ally increasing popular recognition of the fact, however, that
all conduct, good and bad, excellent and defective, depends
upon brain condition, has led, of late years, more and more
to the popular and legal reference of all cases of defective con¬
duct to the medical profession, in the same way other defective
functions are referred to them.

Properly, because it is a legal term, insanity simply means
that the person has reached such a degree of aberrant conduct
that he has to be supported, controlled, or restrained by others,
or by the state — he is disabled to that degree. It is always
a question of degree and a matter of opinion. The doctor’s
opinion is taken as of most value.

Insanity indicates an extreme degree of cerebral defective¬
ness, which implies that there are other grades of impairment
above the insane level. This is a fact open to every-day veri¬
fication, and it .is a fact particularly related to the subject be¬
fore us. Intoxication can be shown to be the cause of dif¬
ferent grades of defective conduct ranging all the way upward
from the insane level.

Cerebral intoxication varies in the person according to
two factors .of sets of factors; the first is the character of the
agent and the amount of it in the circulation; the second is
the peculiarity of the particular brain, peculiar in the way of
being more or less sensitive to the particular agent, or peculiar
in the way of being inherently defective, which abnormality
is rendered more apparent by the action of the toxin. In

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Intoxication and Insanity.

333

other words, intoxication varies according to the toxin and
the dosage, and according to the abnormality or idiosyncrasy
of the particular brain.

Subjectively considered, by the man himself, the toxin
produces discomfort or comfort. This is the direction in
which he first considers it or principally considers it. In the
action of many, probably of most, toxins, the sentient result
is that of less conscious activity, which means less sensation,
or a more comfortable state.

Consciousness occurs only when there is functional action
going on in the cerebrum; when there is no cellular motion,
there is no consciousness; this occurs naturally in sleep and
artificially in anesthesia; when the brain is partially rendered
less capable of functionating by the chemic action of a drug,
there is diminished sensibility — more comfort. Comfort is
a negative condition, meaning no discomfort. Discomfort
is a constant or most frequent condition of many brains to
whom all cerebral or bodily effort is more or less painful.
Cerebral hyperesthesia is a very frequent condition as a part
of neurasthenia or cerebrasthenia. In this condition the over¬
sensitiveness, in time, is increased by the injurious or chemic
effect of the toxin. If the agent simply stiffen or slightly
harden the delicate structures so as to prevent or to make less
their functional activity, it produces less consciousness —
more comfort. This varies with the character of the toxin,
but in time produces hyperesthesia or neurasthenia.

In intoxication there is more or less a sense of incapacity,
dullness, and confusion; sometimes, a more comfortable state
because there is lessened sensibility. Sometimes, on the other
hand, cerebral effort or activity produces more discomfort,
so that, as a sequel to continued intoxication, comes hyper¬
sensitiveness with irascibility, irritability, forgetfulness, and
worry; all exhibits of cerebral impairment. If the person is
naturally erratic or peculiar or hypersensitive, he is rendered
more so. A cerebrum tending already toward hypochondria,
melancholia, mania, or paranoia, is more inclined that way.

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334

Intoxication and Insanity.

In short, intoxication always injures the cerebrum for the time
being, sometimes permanently, and in certain persons incretses
original defectiveness to the permanency and grade that is
called insanity.

Toxins, such as ptomains, leucomains, and other toxic albu¬
minoids, arise from the disintegrations of disease in the system;
and there are also natural waste products which, if retained
in the circulation, prove highly toxic, such, for instance, as
are eliminated by the kidneys, the liver, the bowels, and the
lungs. Infection comes into the circulation from many direc¬
tions; the scavengering of the system is most important work
on that account.

Macrobic disintegration of cerebral structure proper is not
often seen. Inflammation of tubercular bacilli occurs in the
meninges, and other meningeal inflammations are said to be
microbic; cerebral syphilis may be this. Upon the true
functionating structures of the cerebrum, however, microbes
most often have no direct, but indirect effect by the toxins
they produce elsewhere.

Diseases affecting the general system, like the exanthems,
fill the circulation with toxins. Some brains are very sensi¬
tive under these conditions, and delirium is a consequence;
there is always more or less confusion, dullness, listlessness,
and incapacity, as a consequence of such intoxication. In
the extreme of life, in articulo mortis , the complete arrest
of cerebration from this cause, in a large number of cases, re¬
moves the pain and distress of dying.

Cerebral toxicity, from disease in different organs of the
body, varies with the organ. Diseases of those organs whose
function it is to remove waste toxic material are always serious
to the brain. The kidneys, liver, alimentary canal, lungs, and
skin are organs of this character. We often have the unre¬
moved waste toxins of the system in the blood added to those
directly produced by the inflammatory disease of the excretory
organ. Acute rapid disease of such organs often produces
delirium; more chronic disease for this reason sometimes gradu-

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Intoxication and Insanity .

335

ally induces the more permanent condition of insanity. The
delirium and the insanity indicate, usually, brains already
sensitive, weak, and defective.

In an insane hospital, where the worst cases of defective
cerebra are found, it is very easy to note the effects of auto¬
intoxication. The part the digestive tract plays in the role
of insanity is often very evident. In conditions of certain
forms of dyspepsia, particularly in conditions of constipation
or torpidity, auto-intoxication can be shown, and its relief
demonstrated by removing the toxin by cathartics and alimen¬
tary disinfection. Stercoremia, copremia, and the common
condition, “ biliousness,” afford instances of it.

A large proportion of the insane suffer from some form
of nephritis, and to it can be traced many of their more insane
periods or “ spells/’ when the already weak or defective cere¬
brum is made more aberrant by uro-toxicosis.

Toxemia in women, during gestation, and after their con¬
finement, during uterine involution, especially if there is sepsis,
and during lactation, is by no means an uncommon thing.
Puerperal mania or insanity in some form, is a result in ex¬
treme cases. It is a rare thing that the parturient woman
shows no signs of intoxication in some of its milder forms.

A long chapter could be written on autointoxication.
Literature on this subject is getting more and more abundant.
I have said enough to show its importance as it relates to
insanity.

Intoxication by agents introduced from without is a fre¬
quent occurrence, and, as it relates to brain hygiene, is little
appreciated.

As physicians, we would be very much handicapped in our
practice if we did not have cerebral toxins among our medi¬
cines. They constitute a very popular line of drugs; popular
with the doctor, because popular with his patient. All ano¬
dynes and anesthetics are of this class. Most frequently the
urgent symptom to be relieved in our patient is pain or dis¬
comfort. Pain is a brain condition. If disturbed or disin-

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336

Intoxication and Insanity.

tegrating action in distal parts cannot be conveyed to tbe
sensating brain by nerve lines that we have rendered in¬
capable of transmitting by our toxin, there is no sense of it;
or, if we render the cerebrum unconscious by our toxin, we
accomplish the same object, there is no pain. We accomplish
artificial anesthesia with such an agent as chloroform by a com¬
plete suspension of cerebral functions, while the functions of
the lower centers, which adjust internal actions, are left to
continue. If we push the anesthetic farther we suspend them
also, fatally to our patient.

Toxins nowadays are known also to have injurious effects
upon peripheral nerves. Peripheral neuritis is now ascribed
most often to this cause, in conjunction with exposure, fatigue,
or some such condition which renders these nerves more sensi¬
tive to the toxin. Peripheral pains, such as make so promi¬
nent a symptom in grippe and dengue, probably have this
source — headaches, sometimes.

I believe it is true, under certain conditions or with some
toxins, toxicity can be of the peripheral nerves at the same time
and by the same agent that the cerebrum is affected. The
difference between an anodyne and an anesthetic may be this:
the one affects more generally the nervous system, the other
principally the cerebrum. This distinction is necessarily not
well drawn. It is a good hypothesis, however, that anodyne
or anesthetic effect in the relief of pain or discomfort occurs
by the arrest of the function of the transition of motion along
nerve lines, or most frequently, by the arrest of conscious mo¬
tion in the cerebrum. The anodyne, cocaine, administered hy¬
podermically, hardens chemically the nerve lines leaving the
locality, so there is no transition of motion to the sensorium
from the part, and no pain; though later, we have its anodyne
effect on the cerebrum, obtunding in a general way the sense
of disintegrating action or pain.

The effects of alcohol, on the other hand, generally begin
in the cerebrum; though we do have local anesthesia in tbe
stomach, and in time, in some cases, neuritis in the periphery

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Intoxication and Insanity .

337

as an effect of it. We may correctly suppose that whenever
we arrest or abate pain with a toxic agent, we do it most often
in the brain by hardening the axis-cylinders of nerve lines,
or the central part of nerve cells, in this way preventing or
lessening their functional motion. A good deal is being
written to show the changes in the nerve cells of the cortex,
in the way of enucleation, diminution in size, and changes in
length and shape of processes by the continued use of certain
toxins. Degeneracy of axis-cylinders in nerve lines elsewhere
is also reported. The cerebrum (the sensorium) is the most
important organ that suffers; it is impaired by the excessive
or the continued use of anodynes a^d anesthetics, in numbers
of instances.

In many persons the effect of the continued use of such
agents on their peculiarly susceptible or defective cerebra is
so injurious as to increase the original condition of-over-sensi¬
tiveness to neurasthenia, or to carry their original defective¬
ness or weakness to the stage of permanency and degree called
insanity. The continued use of such agents as luxuries, be¬
cause of the artificial comfort they give, works widespread
harm. The popular and extensive use of alcohol and nicotin
as luxuries, not to mention other toxins, leads to increase of
cerebral and neurotic defectiveness and disease and, in some,
induces the extreme cerebral condition of insanity. A narco-
maniac or an inebriate, in the large majority of cases, has had
an original defect of brain, preceding his drink habit, that has
been rendered more decided by repeated intoxication. The
brain is a very much abused organ, and one sorely omitted in
our private and public sanitation. In the use of such agents
as luxuries, the brain effect is the one sought after, and in
proportion to the amount taken and the length of time, injury
is done. Intoxication, owing to inherent peculiarities, is more
injurious to some brains than to others.

Vol. XVIII — 54 .

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338

The Effect of Acute Alcohol Poisoning

ON THE EFFECT OF ACUTE ALCOHOL POISONING
ON SIMPLE PSYCHICAL PROCESSES.

From The Medical Pioneer.

Among the numerous, interesting, and valuable papers pre¬
sented at the International Congress against the misuse of al-
- coholic liquors in Basle, la(it year, there was none more impor¬
tant from a medical point of view than that of Dr. C. Fiirer,
assistant in the Clinic of Psychology, Aeidelbery, having the
above title. This paper has just been published in full in the
printed report of the Congress, and we shall now give an ac¬
count of it. It gives the results of an inquiry into the effects
of a single dose of alcohol, varying in quantity, but fairly large
and of the kind and duration of the after effects of a single mod¬
erate “ excess ” of alcohol. The experiments of which the
principal results are here given have been partly previously
published by Professor Kraepelin, and are partly the outcome
of Dr. Fiirer’s own experiments.

All articles of food or drink capable of affecting the men¬
tal processes were rejected during the experiments, and con¬
trol experiments without alcohol were always instituted.

One series of experiments consisted of determining the time
between the giving of a signal (saying “ a ”) and the announce¬
ment that it had been heard, this being measured by a clock,
which was set in motion on giving the signal and stopped by the
person experimented on. (This gave the so-called “ simple re¬
action.”) In the next series there were two signals (saying
“ a ” or “ o ”), the one to be acknowledged by the right hand,
the other by the left (decision reaction). The average of 100
experiments was taken and, in the case of the decision reaction,
the proportion of mistakes.

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on Simple Psychical Processes . 339

In a series of experiments on association of words, the act
of opening the lips to say the word set an electric current in
motion, and the response set free another, and the time was
measured as before.

In experiments to estimate time, the person sat with shut
eyes, and concentrated his attention on intervals of time (30
seconds), which were marked by calling the word “ now.”
Then twenty-five times running he had to estimate the time
between two such calls, which was checked by a watch.

Another series of experiments was made on the action of
alcohol on muscular activity and its checking of muscular fa¬
tigue. Trials were made with the ordinary hand dynamo¬
meter, and also with an ergograph, after the model of that of
Mosso. A finger was hooked in a loop of string which passed
over a pulley and lifted a lever when the finger was bent, and
this lever marked a line on a revolving drum. The Test of the
hand was fixed, and the finger was bent at regular intervals
following the movement of a metronome.

Kraepelin’s experiments were made with varying doses of
alcohol. The lowest dose was 7-J grammes (about two fluid
drachms) and the highest 60 grammes (about two fluid ounces)
of alcohol, equal to from one-fifth to two litres of 4 per cent.
Munich beer. The result was that for all the psychical pro¬
cesses investigated (simple and decision reactions, association
experiments, addition, learning by heart and reading, dyna¬
mometer trials and estimations of time), with doses of from
30 to 45 grammes (1 to 1^ fl. oz.) of alcohol (f to 1 litre
of beer or ^ to f litre of light wine) a more or less increased dif¬
ficulty or embarrassment was shown. The duration of this
difficulty increased with the size of the dose, with certain vari¬
ations which depended on the temporary condition or idiosyn¬
crasy of the person experimented on. This difficulty continued
after each dose from three-quarters of an hour to several hours.

The results with regard to these processes separately was
that, with the simple reaction and reaction of decision there
was at first a state of excitement, inasmuch as the time of re-

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340 The Effect of Acute Alcohol JPoisoning

action was shorter than under normal conditions. But this
excitement lasted only a short time, giving place to a notable
depression. With larger doses the depression came on at once
as a rule, or the shortening of time was but very brief. This
showed that alcohol, as was before known, possessed the prop¬
erty of producing a quickening of movement. This has been
commonly observed in company after the use of intoxicating
drinks; the inclination shows itself in individuals to gesticu¬
late and respond generally to various stimuli, while afterwards
a gradually increasing slowness of movement takes place.

But the experiment also shows that after even such small
quantities as 7^ grammes (2 fluid drachms) the appearance of
paralysis (to which we must attribute the lengthening of the
reaction-line) is inevitable, and that at the best an improve¬
ment can only be said to occur at the very commencement.

In the association experiments we also find a preliminary
stimulation in that the time taken for establishing the associa¬
tion is a little shorter. But yet this by no means appears to
be an improvement of power, but rather the reverse, if the char¬
acter of the associations is taken into consideration. For in¬
stance, the external associations, specially rhyme, improve at
the expense of the internal ones. The external associations,
however, represent those of least value. We here find also
that experiment is in accordance with the facts observed in com¬
mon life. We can readily place the tendency to make poor
jokes under the influence of alcohol on the level of association
of rhyme, as in both cases it happens that a connection of
thoughts, or, properly speaking, of words only, is less due to
thought than to external associations. The increased output
of the reflex-motor processes (speech) caused at first by alcohol
plays a part here also, and this can be explained by the fact
that certain inhibitions are removed which, in normal circum¬
stances, would prevent the expression of less worthy associa¬
tions. Besides this paralysis of inhibition we can also recog¬
nize a paralysis of the higher psychical powers in so far that
while there is a freer entrance of associations of a lower de-

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341

on Simple^Psychical Processes .

gree, based, for instance, on resemblance of sound, higher as¬
sociations depending on ideas, at least of the first rank, are
found to be impossible. During the succeeding depression the
deterioration continues, and the times are longer, and this is
also in accordance with general experience.

The same preliminary improvement and subsequent de¬
terioration is found in the reading experiments , in which they
had to read as much as possible in a certain time without regard
to the sense; the number of syllables was greater at first and
afterwards less.

A combination of reflex processes and mental work in a nar-
now sense was found in the experiment on learning by heart.
At first we also find here as a rule a facilitation of repetition and
learning, although in some of the subjects there was a diminu¬
tion of the rapidity of learning from the beginning. With
doses of 30 grammes (about 1 fluid ounce) of alcohol diminu¬
tion as a rule sets in from the first. The repetition consisted
chiefly of the motor element of speech.

The addition experiments showed that, just as with the
association experiments (commencing with 20 grammes [about
5 drachms] of alcohol) there was a deterioration, inasmuch as
for this kind of mental work the time required proved con¬
siderably longer than under normal conditions and the amount
of work done in a given time was less.

The experiments which aimed at the investigation of the
performance of work by the dynamometer and ergograpli
showed that there was a temporary facilitation, demonstrated
by a higher mark of the pointer of the dynamometer and a
higher point of the ergograph curve, but that the fatigue of
the muscle set in very soon; the curve of the ergograph soon
fell below the normal level. The curve is indeed longer than
that furnished under, for example, the influence of tea, yet
close investigation shows clearly that the increase of work
performed is only apparent. The last part of the curve is only
a very slight elevation. The time during which the muscle
would work was indeed longer, but the total amount of work

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342 The Effect of Acute Alcohol Poisoning

does not correspond to the length of time it took; this amount
under alcohol is decidedly less. The conclusion is that under
the influence of alcohol the muscle will work longer and do
less. This throws an interesting light on the popular idea
that the use of alcohol facilitates bodily work. Experiment
shows clearly how the subjective sensation of increased cor¬
poreal power comes about. The individual under the influ¬
ence of alcohol is able to do some work for a longer time, but
the diminished value of the work is not evident to him, the
fatigue is regarded as coming on normally while it is never¬
theless in consequence of a special paralyzing effect of alcohol
The fatigue which comes on without alcohol a little earlier
leads to an earlier rest and then the work is resumed with really
fresh power, and in the same period more is done, both in quan¬
tity and quality, than under alcohol.

In the experiments on the estimation of time symptoms of
fatigue set in earlier under the influence of alcohol.

Summing up these results we find most decidedly that even
with very small doses (7-J grammes or 2 fl. drachms) the weak¬
ening or paralyzing action of alcohol sets in in the course of
each experiment, and that only an improvement of the motor
process is experienced, but that this improvement is very
doubtful, as the quality of the work is not so good. The quan¬
tity of alcohol which perhaps may exercise a purely stimulat¬
ing effect on the bodily functions, if such a quantity can after
all be defined, must be very small, far smaller than can come
in question in practical life, as a commonly taken quantity of
alcohol. It must bfe less than 7 \ grammes of alcohol, and in
one-fifth of a litre (about a quarter of a pint) of Munich beer
and one-tenth litre of w T hite wine (one wineglassful) there is
more than this quantity. With the use of such surely trifling
quantities of spirituous liquors, the paralyzing action must be
taken into the bargain.

Turning now to the results of the experiments on intoxi¬
cation. It is expressly noted that in every case there was only
slight intoxication, so little that in most its existence was only

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on Simple Psychical Processes .

343

noticeable to the subject of the experiment, and not at all to
the bystanders. There were never any after-symptoms. Dur¬
ing the experiment there was never the feeling that it could
affect his woi*k. This subjective feeling of the resultlessness
of the experiment was confirmed from another side. The ex¬
periments were so arranged that a normal experiment of the
same length corresponded to each trial of intoxication and em¬
braced decision, association, learning by heart, and addition.
There were, in the course of one such group of experiments,
3,600 trials of decision, about 30,000 numbers added and
about 19,000 numbers learnt by heart. A very temperate life
was lived, the use of tea, coffee, tobacco, and other things which
might affect the nerves, was abandoned and all fatigue avoided.
All the experiments gave in the main the same results. Indi¬
vidual differences never showed that any of the works per¬
formed was improved.

.The following tables make clear the conclusions of the
text:

TABLE I. — DECISIONS.

Normal Condition.

1st day.

13th shortest, ... 313 363 358 306 336 346

Mean,. 398 418 421 374 409 412

13th longest, .... 475 477 479 473 504 474

Spread, ..... 162 114 121 167 168 128

Mistakes, $.• .... 5 1 1 4 6 5

2d day.

13th shortest, ... 345 354 340 329 307 335

Mean,. 419 446 419 418 366 411

13th longest, .... 499 502 493 485 449 489

Spread,. 154 148 153 156 142 154

Mistakes, #. 2 1 3 4 2 7

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344

The Effect of Acute Alcohol Poisoning

3d day.

13th shortest, ... 362 354 360 317 335 376

Mean,. 428 420 471 390 404 460

13th longest, .... 499 506 556 465 474 528

Spread,. 137 152 196 148 139 152

Mistakes, #.8 3 1 4 6 3

After Morning Intoxication.

1st day.

13th shortest, . . . 348 221 221 271 240 264

Mean,. 406 380 400 428 364 400

13th longest, .... 469 476 540 516 463 482

Spread,. 121 255 219 245 223 218

Mistakes, #.1 16 18 11 19 19

* 2d day.

13th shortest, . . . 277 294 323 333 299 280

Mean,. 378 408 405 434 399 396

13th longest, .... 478 507 512 540 510 500

Spread,. 201 213 189 207 211 220

Mistakes, £. 16 10 22 18 18 16

3d day.

13th shortest, ... 337 331 264 231 248 258

Mean,. 406 396 314 293 300 304

13th longest, .... 485 472 377 354 362 364

Spread,. 148 141 113 123 114 106

Mistakes, #. 8 2 3 7 3 6

Each column gives the result of 100 acts of decision. The
numbers signify thousandths of a second. The thirteenth
shortest reaction is given, and the thirteenth longest, as well

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on Simple Psychical Processes .

345

as the average, and the difference between the longest and
shortest or “ spread ” of the reaction-times. This, in the nor¬
mal condition, is not very considerable, although difference
must be expected because the trials were made on different
days, and times of the day. The lowest row of figures gives
the percentage of mistakes made.

In the case of the intoxication trials, half a litre (about 18
ounces) of Greek wine was taken, equal to about 2 litres (3^
pints) of small beer. The first column shows the condition
just before taking the alcohol. The figures alter entirely af¬
terwards. The “ spread ” of the reaction times is much in¬
creased and also the percentage of mistakes. We find that
some very short reactions occur (the effect of alcohol in stim¬
ulating the motor-processes) [this is probably due to the action
being more automatic or reflex and less directed by voluntary
or will power — E. Medical Pioneer] in connection with par¬
ticularly long times in which the paralyzing effect is already
showing itself. Looking at the mistakes we find that the
shortening of the time of reaction in very many cases indi¬
cates a deterioration, as the question is evidently not how to
make an accurate decision, but simply to move a hand at the
signal, whether the right or the wrong one.

It is also very interesting and extremely important that
this parading effect of alcohol was experienced, in spite of a
good night’s rest, and although absolutely no after-effects were
subjectively felt: this continued during the whole of the sec¬
ond day, and first began to disappear on the third. We see
this most clearly from the proportion of mistakes, which again
came down to normal on the third day. The shorter times of
the last four rows were due to extraneous conditions, which
had nothing to do with the experiment. The general result
was in no way altered, as the proportional spread is the same.

In Table II we have the comparative experiment of addi¬
tion without and after alcohol (f litre of Greek wine = 3 litres
of 4$ beer) taken in the evening.

Vol. XVIII—55

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346

The Effect of Acute Alcohol Poisoning

TABLE II. — ADDITION.

Normal Condition. After Alcohol.

1st day,. 1223 1st day, 1215 (just before.)

960 (soon after.)

2d day,. 1308 -

1370 2d day, 1142

1371 1148

1329 1240

- 1239

3d day, . . . 1336 -

1346 3d day, 1267
1326 1325

1368 1284

- 1269

4th day,. 1377 -

1396 4th day 1321
- 1309

These numbers indicate the total reached by addition in ten
minutes. It will be seen that in the normal condition the
numbers mount up on the second day to almost a level, which
is maintained on the third, and even increases on the fourth.
After alcohol there is a notable fall, and there is also a dimi¬
nution on the following day, and there is not a fair number
reached until the third day, though the performance is alto¬
gether less than when free from alcohol. The author special¬
ly emphasizes the fact that he never felt any indisposition on
the day following the taking of the alcohol and that he had
good rest at night, indeed he felt that he had slept better than
usual, and awoke more quickly, although he was less able to
work.

The experiment of learning by heart (Table III) shows
again most clearly the injurious and long-lasting effects of an
intoxication. In the evening after drinking wine there was
a notable diminution of power, the whole following day still
considerably less performance than one had expected accord¬
ing to the normal action; on the morning of the third day there
was still an abnormally small performance and then first a

Digitized by CjOOQle

on Simple Psychical Processes. 347

disappearance of the effect of alcohol. The table shows how,
in the normal condition, the capacity for learning by heart in¬
creases day by day. The numbers are the totals of the number
of figures learned in ten minutes. #

TABLE III. — LEARNING BY HEART.

Without Alcohol. After Alcohol.

1st day, ...:.. 777 1st day, 576 (just before.)

808 370 (just after.)

2d day, . . . . . . 864 2d day, 622

813 522

900 .651

876 608

3d day,.912 3d day, 714

930 ~ 900

756 792

966 888

4th day,. 900 4th day, 864

996 ' 816

In Table IV the results of a series of experiments on as¬
sociations are given. Associations are of different value, the
inner or mental associations being of higher value than those
which are external or affecting the senses. In this table the
relative position of the associations of sound , which are of
the very least value, are compared with the inner, and both
kinds shown in their proportion per cent, to the total of all
kinds furnished by a single experiment. It is intended to
show the proportion of the worst elements of the associations
under the influence of alcohol. By examining the first fig¬
ures of the normal condition it will be seen that the sound as¬
sociations (2d column) are quite immaterial compared with
the higher or inner associations, namely, 2 per cent, compared
with 66.4 per cent.

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348

The Effect of Acute Alcohol Poisoning
TABLE IV. — ASSOCIATIONS.

Without Alcohol.

1 After Evening Intoxication.

fit day,

All.

. 66.4

Hou ml
Onlv.
2.6

68.7

3.4 (just before.)

67.3

4.0

44.2

18.5 (soon after.)

2d day, . .

. 74.2

1.8

33.3

25.9

65.3

4.0

51.2

16.5

63.6

1.3

56.6

12.7

68.6

2.1

61.9

10.2

3d day,

. 64.2

4.6

65.1

6.9

57.9

3.4

73.2

2.7

56.1

4.7

67.5

3.7

• 58.2

1.5

73.8

1.8

4th day, .

. 72.3

2.3

71.8

2.4

56.3

3.1

72.7

2.7

With the diminution of the higher associations, the sound
associations considerably increase, and reach the highest rela¬
tive point on the following morning, and then slowly sink
again. Even on the second morning their proportion is ab¬
normally large at first, but on that day first becomes normal.

What do these intoxication experiments teach? They
show in the first place that even a slight degree of intoxication
influences the capacity for work unfavorably for many hours,
certainly all kinds of mental work which take recognizable
shape. An “ early pint ” makes its effects felt, even on the
evening of the following day, and in the same way also an
amount of alcohol in the evening which is still within the lim¬
its of “ moderation.” We see, however, that the effect varies
for different kinds of work; that learning by heart and asso¬
ciations do not return to normal till the morning of the sec¬
ond day following. And all tips after an “ excess ” which
never produced noticeable intoxication nor a “ morning head¬
ache.” These results have a very practical application. They
indicate what an enormous amount of working power is lost
in consequence of the common use of alcohol. This loss is
not recognized by the subjects of it, and is only proved by
exact experiments. The author had no idea that these results
would be obtained, and had not expected anything important;
he was astonished and appalled at their weight and character.
He thinks that they will prove a powerful weapon in favor of
temperance.

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Obstacles to Treatment of Alcoholic Inebriate. 349

OBSTACLES TO THE SUCCESSFUL TREATMENT OF
ALCOHOLIC INEBRIATES.

C. Spencer Kinney, M.D., Middletown, N. Y.

Asst. Physician to New York Stats Hospital Jot Lunatics .

Read at Rochester before the Homeopathic Medical Society
of the State of New York , September 23,1896.

The confidence which is born of uniform success is not
always rotund in the treatment of alcoholic inebriates, but
is frequently pretty well attenuated after one has had the
usual experience with them. It is not that the inebriate does
not want to get well, for he generally says he does and tries,
though frequently failing; and sometimes he gets sober and
keeps sober.

When a victim of drink comes to the doctor asking for
help, begging that something be done to enable him to regain
his self-control, promising that on his new trial he will surely
redeem his unfortunate past and once more become a man, and
accompanying these promisee with particulars as to how much
is depending on him, no one can help, under such circum¬
stances, taking hold and doing the best that medical experience
renders possible.

The inebriate oomes to the doctor with his system clogged
up and poisoned, and with the functions perverted, with the
hope that internal medical treatment may enable him to lead
a new existence. In this belief he is supported by his friends,
who fervently hope and believe that internal medical treat¬
ment is going to render him incapable of ever returning to his
unfortunate habits. He may relapse, and then his friends
are the first to find fault with the instability of the cure. This
must be taken philosophically, with the understanding that
human nature is weak, and that human intelligence has its
limitations.

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850

Obstacles to the Successful

The more one studies the class of individuals from which
alcoholic inebriates come, the more one is convinced that they
resemble the poets in that they are “ born,” and not wholly
“ made.” The pleasant social qualities, so frequently shown
by the victims of the drink habit, lead them into convivial
associations in which drink becomes the chief form of enter¬
tainment, and in the indulgence of which their appetite be¬
comes aroused. They belong to that class of good fellows of
whom their friends speak pleasantly, and, when occasion offers,
with charity, frequently admitting that the sole cause of their
lack of success in any effort in life is the one habit of drinking.

Back of all this, in which heredity plays an important part,
in which the influence of early training and associations must
be fully understood, is the necessity of possessing a healthy
will-power, which will enable them to carry out a resolve,
intelligently and conscientiously taken, that drink in all forms
must be avoided if they would succeed in whatever they under¬
take. If there is one thing of greater importance than an¬
other in anticipation of a successful outcome of treatment for
the drink habit, it is that the patient possess a fairly strong will
power. Unless this be the case, the chances are that no treat¬
ment will result in much more than a sobering-up affair. The
development of the will-power, like the development of any
other faculty, may depend on healthy bodily conditions. The
will-power can become enfeebled by the continuance of de¬
teriorating habits just as readily as memory becomes impaired
by careless reading.

In the case of the morphine habitue we expect and find
that there is an acquired difficulty in stating facts. In the
alcoholic inebriate we do not always appreciate the reason for
possessing feeble will-power. If, however, we accept, and I
believe we have every reason to so accept, the fact that the
use of liquor engenders a benumbing or paralyzing effect upon
the healthy exercise of conscientiousness and judgment, we
find in their place a cloudy moral perception and a capricious
judgment, and the will-power, as a controlling factor, pos-

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Treatment of Alcoholic Inebriates .

351

sesses but little of its original healthy strength. There is
established an automaticity of action to the extent that when
the desire and opportunity for drink are met, indulgence is
the result.

In a life without object, withotft ambition, idleness will
destroy the self-control of an individual as thoroughly as any
other form of dissipation; while, on the other hand, plenty of
methodical employment that exercises the mental power and
intelligence of the individual will do much in developing and
maintaining the will-power in those cases in which this treat¬
ment is necessary.

Perhaps one of the most pernicious habits in enervating
one’s self, and one in which the memory, continuity, moral
sense, powers of perception, as well as the will-power become
weakened, owing to impaired nutrition of the blood, is that of
cigarette smoking. From observation I have come to believe
that few, if any, of those who need treatment for inebriety
can be successfully treated so long as they indulge in cigarette
smoking. The practice of inhaling the smoke so constantly,
as is the habit of the cigarette smoker, has the effect of keep¬
ing the lung tissue thoroughly impregnated with it, and pre¬
vents the blood from becoming properly oxygenated. The
fact is that for little or no time during the twenty-four hours
is it possible to have fresh blood sent throughout the system.
This will account for the offensive odor that invariably en¬
circles the cigarette smoker, prominent in breath and perspira¬
tion, and shown also in the peculiar sallowness of the skin,
in the lack-luster expression of the eyes, and in the listless
manner that betokens the characteristic physical enervation
of this class of patients. Moreover, the mouth and throat
of a cigarette smoker are kept in a degree of irritation that
accentuates the desire for drink more than would otherwise
be the case.

The telling of degrading experiences, under the idea that
the stories are “ funny,” is common to those under treatment
for the drink habit, and is one very serious objection to treat-

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352

Obstacles to the Successful

ing a number under the same roof; for a man who considers
that a cause that has wrecked his own life and the happiness
of those dependent on him, is but a joke of which he is the
hero, is not in a mental condition to appreciate the necessity for
treatment for his habit, # nor does he possess a conscientious
desire to free himself from it. “ As a man thinks, so is he ”
is well illustrated in this phase of the obstacles in the way of
treatment.

The excuses made by an inebriate for drinking are seldom
worthy of much consideration. So strong is the desire to find
an excuse that, intentionally or unintentionally, a truthful
statement is avoided. In most cases when the desire and the
opportunity come together he succumbs. When no oppor¬
tunity offers and the desire is strong within him he is ingenious
in his method of securing an opportunity, and reckless to the
extent that he will throw aside all moral, social, and intellectual
claims to decency, and will sink to the greatest brutishness that
his end may be accomplished.

Physical disease is many times given as an excuse for drink¬
ing. This excuse must be taken with care. It may be a true
statement, or it may not be. There is no douibt that some
patients become addicted to drink by careless prescribing by
members of the medical profession, and there is no question
that liquor as a “ home remedy ” is often employed to the
detriment of the party taking it.

In a general way, I would say that any enfeebling physical
disorder must be carefully treated before the liquor habit,
that the patient has formed, can be considered. Everything
must be done to establish the natural integrity of the will¬
power, to encourage good habits by avoiding old associations,
by giving up cigarette smoking wholly where this habit has
been formed, and by having regular and systematic work,
with plenty of fresh air, nutritious diet, and willingness to do
precisely what is required of him by the physician in charge.
Good intentions must be supported by patience and time.
During their treatment they reach a period in which they have

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Treatment of Alcoholic Inebriates.

353

unbounded confidence in their own strength, and are profuse
in their promises to let drink alone, begging to be trusted, and
using the most solemn pledges to create impressions of their
trustworthiness. At such times the one who directs their treat¬
ment must be governed, not by what they say, but by what his
past experience has taught him. They cannot be trusted at
a period in which there is a peculiar mingling of the emotional
state, with marked irritability, and a profound desire to have
everything they say taken in earnest.

In a recent lecture by Dr. Banham, professor of Clinical
Medicine at the Sheffield Medical School, occurs the following:

“ Again, the public mind is still to be awakened to the
danger of allowing alcohol to be taken by the children of
families in which nervous diseases prevail — in which there
is, so to say, a defective nervous organization. The existence
in a family of epilepsy, drunkenness, insanity, or even the
milder disturbances of neuralgia, sick headache, or hysteria,
would lead any cautious doctor to recommend its members
entire absence from alcohol. Dr. Savage, whose opinion upon
insanity is universally respected, says that every variety of
insanity may be started by drink, and that it is a very prolific
agent in causing insanity. Dr. Maudsley, in his ‘ Pathology
of the Mind/ deals largely with the transmitted craving for
alcohol, and he points out that the acquired disease of the
parent is the inborn heritage of the child. Terrible, there¬
fore, indeed, is the responsibility attaching to the parents who
allow alcohol to be taken by their children, when a tendency to
drunkenness and nervous diseases has already revealed itself
in their families.”

Vol. XVIII—56

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354

The Medical Treatment of Inebriety.

THE MEDICAL TREATMENT OF INEBRIETY *

By T. D. Crothers, M.D.

Supt. Walnut Lodge, Hartford , Conn.

Inebriety is a more complex disease than insanity. Its
progressive degeneration often dates back to ancestors, to de¬
fects of growth, retarded development, and early physical and
psychical injuries.

Later, the poison of alcohol, by its anaesthetic and paralyz¬
ing action, develops more complex states of degeneration, the
form and direction of which is very largely dependent on con¬
ditions of living and surroundings.

The psychical symptoms show progressive disease of the
higher brain centers, both masked and open, with degrees of
palsy and lowered vitality.

In insanity many definite pathologic conditions are trace¬
able. In inebriety a wider, more complex range of causes
appear, the line of march of which is often traceable in more
general laws of dissolution. Its medical treatment must be
based on some clear idea of what inebriety is, and the con¬
ditions present in the case to be treated.

This requires a careful clinical study of the symptoms,
tracing them back to causes, and all the varied conditions form¬
ative in the progress of the case.

In such a study, heredity appears as the most frequent
early predisposing cause.

The question then is, What conditions of life have been
most active in developing these inherited tendencies? How

* Read before the New York State Medical Association, New York City,
October 15, 1896.

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The Medical Treatment of Inebriety. 355

can these conditions be checked and prevented? What means
and methods are possible in the rational treatment?

The second class of cases most commonly noted are those
due to physical causes. These are the physical and mental
strains and drains, also injuries both physical and psychical.
The remedies here are distinct, and the means to build up and
restore these defects call for therapeutic skill and judgment.
A third class of inebriates seem to be due to especially psychical
causes, of which mental contagion of individuals, of condi¬
tions and surroundings are most prominent.

Here another class of remedies and therapeutic measures
are required. These classes are often combined, and the vari¬
ous causes are blended, requiring more accurate study to de¬
termine the leading factors in each case. These are condi¬
tions which provoke the early use of alcohol, and give form and
direction to the progress of the case.

The second part of the clinical study of inebriety is the
effect of alcohol. What injury has it caused? How far has
it intensified all previous degenerations, and formed new path¬
ological conditions and sources of dissolution? Also what
organs have apparently suffered most seriously from the drink
impulse? and, most important of all, how far is the use of
alcohol^a symptom or an active cause?

Having ascertained these facts, the medical treatment is
the same as in other diseases, the removal of the exciting and
predisposing causes, and building up the body.

The first question is the sudden or rapid removal of alco¬
hol. If the patient is alarmed, and intensely in earnest to ab¬
stain, he will consent to have the spirits removed at once. If
he is uncertain, and has delusions of the power of alcohol to
sustain life, the withdrawal should depend on circumstances.
The removal of all spirits at the beginning of the treatment is
always followed by the best results. The reaction which fol¬
lows can usually be neutralized by nitrate of strychnia, one-
twentieth of a grain every four hours, combined with some acid
preparation. Soda bromide, in 50 or 100-grain doses every

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356

The Medical Treatment of Inebriety.

three or four hours will break up the insomnia, and cause sleep
the first two nights.

The withdrawal of spirits should always be followed by a
calomel or a saline purge, and a prolonged hot-air or hot-water
bath, followed by vigorous massage. Hot milk, hot beef tea,
and in some cases hot coffee, are very effectual. If the patient
persists in a gradual reduction of the spirits, strychnia, 1-20 of a
grain, should be given every two hours. The purge and hot
bath should be given every day while the spirits are
used. The form of spirits should be changed from the strong¬
er liquors to wines and beers. Some of the medicated wines
are useful at this time, or spirits served up in hot milk. There
is no danger of delirium from the withdrawal of spirits, par¬
ticularly where baths and purging are used freely. The two
conditions to be treated at this time are poisoning and starva¬
tion. The system is saturated with ptomaines from alcohol,
and suffers from defective digestion. The nutrition is impaired,
and organic growth retarded. Saline or calomel purges, with
baths, meet the first condition, foods and tonics the second.
Not unfrequently the withdrawal of spirits reveals degrees of
brain irritation and exhaustion, that are practically manias and
delirium, or dementia and melancholia. The essential treat¬
ment is to regulate the nutrition and elimination, then arsenic,
strychnine, phosphates, and iron will comprise the chief rem¬
edies that are found most useful.

Many of the chronic cases of inebriety reveal dementia
when spirits are removed; others show well-marked paresis,
or tuberculosis. Symptoms which were attributed to the
action of alcohol are found to be due to previous degenera¬
tions. In one case the demented talk and conduct while using
spirits burst into marked dementia when the drug was with¬
drawn.

In another case, the wild, extravagant conduct of the in¬
ebriate appears in paresis when free from spirits.

The removal of alcohol is often followed by tuberculosis,
not suspected before, which apparently starts from some triv¬
ial cause, and goes on rapidly to a fatal termination.

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The Medical Treatment of Inebriety .

357

Rheumatism and neuritis are forms of disease which fre¬
quently appear after the withdrawal of spirits. Diseases of
digestion are common, also diseases of the kidneys. The lat¬
ter is usually masked, and bursts into great activity when alco¬
hol is removed.

These and many other organic diseases suddenly come
into view, and whether they have existed, concealed by the
anaesthetic action of alcohol, or have started up from the
favoring conditions of degeneration caused by spirits, are not
known. The therapeutic requirements must reach out to
meet all these unsuspected disease states which may appear any
time.

The removal of spirits in all cases reveals conditions of
both physical and psychical degeneration that call for a great
variety of therapeutic measures.

The next question is to ascertain the special exciting causes,
and remove or build up against them. In the periodic cases
the early favoring causes of the drink storm are often reflex
irritations from disordered nutrition, exhaustion, and exces¬
sive drains or strains. Later, a certain tendency is formed for
explosions of deranged nerve energy in alcoholic impulses for
relief. This periodicity is often due to causes which can be
studied and prevented by remedial measures. In certain
cases nutrient and sexual excesses are followed by a drink
storm.

In another, exposure to malarious influences, where the
disease has existed for a long time before, brings on the craze
for drink. In other cases, constipation, over-work, neglect of
hygienic care of the body, irregularities of food and sleep,
emotional excitements or depressions are followed by an alco¬
holic craze. A vast range of psychical causes have been noted.
Thus, a residence on the seashore or in high altitudes, on
mountains, provokes this thirst for spirits, and removal to high¬
er or lower planes is followed by a subsidence of it. Many
persons never use spirits except in large cities, or at special
exciting gatherings, or on holidays and festive occasions.

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358 The Medical Treatment of Inebriety .

Here evidently some defect of the brain exists, either or¬
ganic or functional, which should be reached therapeutically.

Literally, many of these cases have been cured by change
of surroundings as well as medicines.

While the ostensible object of medication is to stop the
drink craze, this is as far from being curative as the suppres¬
sion of pain by a dose of opium.

Conditions which cause the disordered nerve force to con¬
centrate in cravings for the anaesthesia of spirits, are to be neu¬
tralized and prevented before a cure can be expected.

The use of narcotics and drugs to check the desire for
spirits at the beginning is temporary and always uncertain.
Opium, chloral, and cocaine given freely at this time,
often simply changes the drink craze for these drugs, which are
used in the place of spirits ever after.

The return of the drink impulse at regular or irregular
intervals is in most cases preceded by premonitory symptoms,
which enable the physician to use preventive remedies. In
certain cases cal'omel and saline cathartics, with prolonged
baths, rest, or exercise, according to the requirements of the
case, have been found curative.

Various cinchonia tonics, free from spirits, and iron pre¬
parations are often useful. Large doses of strychnine seem
more valuable after the full development of the morbid im¬
pulse, given when spirits are discontinued. Some of the var¬
ious coca compounds on the market have had a strong influence
in breaking up the drink storm.

In a certain number of cases patients are unconscious of
the approach of the drink storm, and are difficult to treat.
But when they realize its coming and seek assistance, the
task is easier. The general principle of treatment is sharp
elimination through all the excretory organs, and the use of
mineral tonics, changes of diet and living; particularly a
study of the exciting and predisposing causes, and their re¬
moval. When the drink paroxysm has passed away, then
radical constitutional remedies are to be used. The history

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The Medical Treatment of Inebriety . 359

of syphilis calls for mercury, arsenic, and potassium. Defect¬
ive nutrition requires a study of the diet best suited to build
up the tissues.

Entailments from other diseases, as malaria/rheumatism,
and various neurotic affections, require appropriate remedies.

TiAtures of any form are dangerous. The susceptibility
to alcohol is so great that the smallest quantity is felt, al¬
though it may not be recognized.

Where spirits are taken continuously the system is always
depressed; all functional activity lowered, and literal palsy
and starvation are present.

The removal of alcohol is only a small part of the treat¬
ment. The demand for alcohol is a symptom of this pro¬
gressive degeneration. Giving remedies to produce disgust
for the taste of spirits, or to break up the cravings for it, are
not curative. Apomorphia, mixtures of atrophia, hydras-
tine, and a great variety of allied remedies, are all danger¬
ous; while apparently breaking up a symptom of the disease
present, they often literally increase the degeneration by
their irritant narcotic properties, and further depressing action
on the organism. The indiscriminate use of these, and allied
drugs, in the various specifics for inebriety, is the most dan¬
gerous empiricism. It is the same as opium or other narcotics
for pain in all cases, irrespective of all conditions, and calling
the subsidence of the pain a cure. Thus, in the following
cases, a periodic, after a gold-cure treatment, developed into
acute dementia, which ended fatally. In others, epilepsy,
acute mania, pneumonia, rheumatism, nephritis, followed
from the chemical suppression of the drink impulse. In all
probability, the narcotics used were active, contributing
causes to the particular organic diseases which followed.

The masked character of inebriety makes it dangerous to
use narcotics beyond a certain narrow limit. Cases which
have been subjected to active drug treatment, to suppress the
desire for spirits, are feebler and more debilitated than others.
Those who have taken the so-called specifics are marked ex-

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360

The Medical Treatment of Inebriety .

amples, and whether they use spirits again or not, are always
enfeebled and pronounced neurotics.

In all these cases there is so wide a range of causes and
conditions that specific routine treatment is impossible.

Strychnine has recently come into some prominence, and
is a useful, valuable drug. In some cases, where t#B spirits
are withdrawn, its action is pronounced as both a tonic and
stimulant. Given in 1-30-grain doses four times a day, for
a few days at a time, then discontinued, or given in larger
doses for a shorter time, the results are usually good.

In some cases, certain susceptibilities to the action of
strychnia are noticeable, and where the drug is taken to pre¬
vent the drink attack, it sometimes rouses it, seemingly pre¬
cipitating the condition which it is supposed to prevent. This
if often anticipated in the muscular tremors and nerve twitch-
ings that evidently come from strychnia, when used even in
small doses.

Strychnia should never be given alone, except immediately
after the withdrawal of spirits. At other times, combined
with cinchonia or other vegetable tonics, it is an excellent
tonic. Care should be used to watch its effects on the motor
nerves, and be sure that the patient is not unusually sensitive
to it. Belladonna, atrophia, cannabis indica, hyosciamus, and
drugs of this class have a limited value, and should be used
with great caution in states of irritation following the with¬
drawal of spirits. They are best given in combination with
other drugs for a brief time and in particular cases. The bro¬
mides are valuable in the same way, and in the same con¬
ditions, only in much larger doses than mentioned in the text
books. From 50 to 100 grains to a dose are requisite, always
accompanied with baths, and never continued more than two
or three days. Coal-tar preparations are of uncertain value
as narcotics, but may be used in certain cases with good re¬
sults.

The various mineral and vegetable acids are almost indis¬
pensable in selected cases, and often can be given a long time
as tonics.

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The Medical Treatment of Inebriety. 361

In the treatment of eases, after the paroxysm is over, fre¬
quent changes of the form of the tonics are most valuable.
Iron, phosphorus, arsenic, potassa, and bitter vegetable tonics
should be alternated with free intervals, for periods of months.
The various derangements of the system should be watched
and treated with appropriate remedies, and every case should
be constantly under medical care. The facts of the case hav¬
ing been studied, the question of where the medical treatment
can be applied to the best advantage must be determined from
the case and its surroundings.

If at home, the physician must have full control, and his
directions carried out implicitly. When the drink paroxysm
appears, the course of treatment must be prompt and exact.
In one case, the patient goes to bed, and i3 secluded from all
sources of excitement; in another, he is sent away to the coun¬
try, and among strangers ^ in a third case, a few days’ resi¬
dence in a hospital or asylum under the care of a physician is
sufficient. Hospital treatment, with its exact care, and physi¬
cal and psychical remedies continued for a long time, give the
strongest promise of permanent restoration. Wisely adapted
medical treatment, based on a careful study of each case,
makes it possible for the family physician to treat these cases,
in the early stages, with success.

No single remedy is capable of meeting a wider range of
conditions than the Turkish or hot-air baths, with free mas¬
sage. Next to this is hot and cold showers, and hot packs
with free rubbing. Bitter tonics and salines, with regulated
diet, are next of importance. Elimination through the bow¬
els, kidneys, and skin freely, are always essential. Beyond
this, the good judgment of physicians should determine when
to give narcotics, and when to abandon them; always remem¬
bering their danger and very uncertain temporary action.
Also that the cessation of the drink craze is only temporary.
If this is accomplished by drug and chemical restraint, the
permanency is very doubtful.

The subsidence of the drink symptom by the removal of the
VOL. XYI1I—57

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362 The Medical Treatment of Inebriety.

exciting causes, and building up the system to greater vigor
and health, is the only rational treatment. In this, the high¬
est medical judgment possible and the greatest therapeutic
skill are essential for success. The medical judgment, which
will determine the exact condition in each case, and the possi¬
ble range of remedies required; not any one drug or combina¬
tion of drugs; not so-called moral remedies, or appeals to the
will power, but a clear, broad, scientific application of every
rational means and measures are demanded. A large num¬
ber of these unfortunate cases are distinctly curable in the
early stages, and later, when chronic conditions come on, the
possibility of cure continues to a far greater degree than is
commonly supposed.

It is the common observation of everyone that a certain
number of cases recover from the apparent application of the
crudest empirical remedies and psychical agencies used in
the most unskillful way. This fact furnishes the strongest
possible reasons for believing that when inebriety shall be *
studied and treated as a disease more generally by the profes¬
sion, a degree of curability will be attained far beyond any
present expectation. The present empirical stage of
treatment should rouse a greater interest and bring the medi¬
cal treatment of inebriety into every-day practice. Then
the family physician, and not the clergyman and quack, should
be called in to advise.

A new realm of medical practice is at our doors, only
awaiting medical study above all theory, and exclusively from
the scientific side.

Appleton’s Popular Science Monthly is undoubtedly the
strongest science journal now published. The purpose to
give, in a popular form, the best conclusions of recent scientific
study, is carried out with ever increasing completeness in each
number. Such journals need no praise; they commend them¬
selves to every reader.

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Treatment of Alcoholism .

363

TREATMENT OF ALCOHOLISM*

PROM REPORTS OF ARMY MEDICAL OFFICERS RECEIVED AT THE
SURGEON-GENERAL’S OFFICE.

By Dr. C. H. Alden, Assistant Surgeon-General, U. S. Army.

I have received so much pleasure and profit from my at¬
tendance upon the meetings of this society, of which you have
kindly made me a member by invitation, that when called
upon by your corresponding secretary for a paper I was very
glad to respond; but having nothing of my own to offer I have,
by consent of the surgeon-general, grouped together and will
read abstracts from reports of several medical officers of the
army, on the treatment of alcoholism and the drink habit.

It seems to me that this subject has scarcely received the
attention at the hands of the profession generally that it de¬
serves. It has been too much in the hands of charlatans and
proprietors of Keeley Cures. There is no more pitiable object
physically and mentally than an alcoholic wreck, and surely
when such a case is met with in general practice something
better can be done than to call him a drunkard and send him to
an asylum or turn him over to the hands of secret-remedy men.
There are, undoubtedly, many cases which cannot be success¬
fully treated except by taking the patient away from his sur¬
roundings and putting him under restraint, temporarily, but
are there not many other cases occurring in the experience
of the family physician which call for treatment by the regular
attendant, and which can, especially when the patient himself
gives his cooperation, be successfully managed at the patient’s
home? I think, therefore, that efforts such as those of the

* Read before the Medical Society of the District of Columbia , and published
in the National Medical Review , September , 1896.

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Treatment of Alcoholism .

writers of the reports that I shall read, to elevate this subject
from the region of quackery and take it out of the hands
of the charlatan, are commendable. I do not claim for these
reports any special novelty, yet they contain suggestions that
may be of value.

The first report is by Assistant Surgeon T. S. Bratton, a
recent graduate of the Army Medical School, now stationed
at Fort Niobrara, Nebraska, which reads as follows:

“ Post Hospital, Fort Niobrara, Neb., March 24, 1896.

“ To the Surgeon-General, U. S. A., Washington, D. C.:

“ Sir: 1 have the honor to report the results of the treat¬
ment of 52 cases of alcoholism by the hypodermic injections
of strychnine and atropine. As the action of these remedies in
alcoholism is quite well known to the profession it is not deemed
necessary to dwell on the modus operandi. To ascertain
fully the antidotal effects of these drugs nothing was given, as
apomorphine and whisky, to create nausea and disgust for the
taste of whisky; but, on the contrary, the stomach was quieted
and brought to its normal condition as soon as possible. Each
patient, on entering the hospital, was given 0.3 calomel and
0.6 bf bicarbonate of soda, as a routine, to clean out the ali¬
mentary canal. If nausea existed it was relieved by 1 c. c.
each of tincture capsicum and spirits menth. pip. at a dose
and repeated, if necessary, every hour or two. Hot milk and
lime water in small quantities, frequently repeated, was also
used in these cases of irritable stomach with the best results.

“ As soon as the calomel acted the injections of strychnine
and atropine were begun. The usual dose was strychnine
sulphate 0.001 (grs. 1-60), atrophine sulphate, 0.0005 (grs.
1-120). The patient was kept in a condition in which there
was dryness of the throat and slight dimness of vision. This,
of course, required an increase or decrease of the dose according
to the susceptibility of each individual. I found some could
stand larger doses, while others required less. The strychnine
was increased or decreased in the same proportion (1-60 gr.
of strychnine to 1-120 gr. of atropine), and did not produce
the first symptoms of poisoning, tho ? some very large doses were
given. These injections were continued three weeks, and
at the end of that time each patient was given a bottle of
elixir of iron, quinine, and strychnine enough to last a week,

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3.7 c. c. three times a day, and sent to duty. The first week
in the hospital they were all given 3.7 c. c. of tinct. gentian
comp, to increase their appetites. When they were able they
were encouraged to take lots of exercise in the hospital grounds.
The whole object in view was to build up the nervous systems.

“ Many of the cases were voluntary. Some were given a
choice by their company commanders of either taking the
treatment or having charges preferred against them that would
cause their discharge for drunkenness.

“ From the latter class almost all the relapses occurred.

“ In forming an opinion as to the merits or demerits of the
treatment, these facts should be borne in mind. (Signed, T. S.
Bratton, 1st Lieut, and Asst. Surgeon, U. S. A.) ”

The report is accompanied by a tabular list, giving the
particulars in regard to these cases, showing how long each
patient had been drinking before treatment was commenced,
when they were discharged from treatment, their history
since, so far as sobriety is concerned, and the bases which re¬
lapsed. Treatment, it was stated, lasted three weeks. He re¬
ports 52 cases, but of these some of them had been discharged
from treatment so recently that results in their cases could not
be fairly considered. Excluding, therefore, nine cases in
which they have been discharged from treatment two months
or less, vrould leave 43 cases for consideration. These patients
had been drinking, I see, from seven to twenty-six years. Of
these seven have relapsed.

The doctor accompanies his report with letters from the
officers commanding companies stationed at his post, and all,
without a single exception, speak in the highest terms of the
results of the doctor’s treatment in restoring men who have
been chronic drunkards to the position of good soldiers; in some
cases their reformation having been followed by promotion
to non-commissioned officers. Several speak of the point made
by the doctor in his report, that the cases of relapse were almost
all those who had been compelled by their company com¬
manders to take the treatment, and who did not do it willingly.
The co-operation of the patient, therefore, seems to be an im¬
portant element in its success.

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Treatment of Alcoholism. ;

The next report is by Assistant Surgeon E. L. Munson,
also one of the younger officers of the medical corps, stationed
at Eort Assinniboine, Montana. He reports but a single case,
but one worth quoting, especially as his treatment seems to
have been an imitation of that we understand to have been
adopted by some of those who keep secret their methods. "We
cannot deny a certain measure of success to the men who have
taken this unworthy method of treating the drink habit, and if
their successful methods can be carried out openly and upon a
rational basis, it would seem to be good practice.

Report of a case of chronic alcoholism, treated empirically,
with apparent cure, by Edward L. Munson, M.A., M.D., First
Lieutenant and Assistant Surgeon, U. S. Army:

“ Sergeant P. C. has always been considered by his superior
officers as an able, trustworthy, and painstaking man when
sober, but, for .the past ten or twelve years, he has been in the
habit of indulging in a debauch at intervals of three to six
weeks, these debauches lasting days, or even weeks, thus greatly
impairing his efficiency and reliability.

“ He was an irregular, rather than a steady drinker, was
fully aware of the evils incident to his habits, but, while
anxious for reform, appreciated that this could never be ac¬
complished by his own unaided efforts. He had on several
occasions received sedative treatment from me during the late
winter and spring of 1894-5, was in hospital for alcoholism dur¬
ing April, 1895, and finally, on May 9, 1895, was placed in
hospital and a treatment outlined, which, in nine days, re¬
sulted in cure. He entered a hospital after a debauch of a
week’s duration, unable to converse intelligently, breath foul,
tongue coated, and tongue and extremities markedly tremu¬
lous. There was considerable gastric irritation, with consti¬
pation, and a cathartic of magnesium sulphate, with black cof¬
fee and strong beef tea was at once given. A hypodermic in¬
jection, consisting of 0.031 of a grain of sulphate of strychnine,
0.007 of a grain of sulphate of atropine, and 0.123 of a grain
of sulphate of morphine, was ordered to be given three times
daily, and at these times the patient was allowed to drink as
much whisky or brandy as he desired, which was considerable
during the first thirty-six hours of treatment

“ Immediately following the administration of the alco¬
holic the hydrochlorate of apomorphine was given hypoder-

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mically, beginning with a dose of 0.062 of a grain, and gradu¬
ally increasing to 0.092 of a grain, the intention being to pro¬
duce a gradually increasing nausea, which would finally
become so great as to result in actual vomiting. The patient
was repeatedly impressed with the idea that the medicines
administered were incompatible with alcohol, and that their
continued use would result in an intolerance by the system
to alcoholics. All craving for liquors disappeared at the end
of the second day, and on the third day whisky had already
become extremely distasteful, but was ordered continued in
doses of thirty to forty ciibic centimeters, as before.

“ On the fourth day the atropine and morphine were dis¬
continued, and the dose of strychnine was increased to 0.046
of a grain, which appeared to be about the limit of tolerance,
and this treatment continued for three days. On the seventh,
eighth, and ninth days the whisky was omitted once daily,
and at these times a hypodermic injection of distilled water
was substituted for the apomorphine, the previous conviction
that the nausea and vomiting previously experienced were
due to the antagonism between the drugs, and the alcohol
being thus strengthened. At the end of nine days the above
described treatment was stopped, a simple tonic of nux vomica,
cinchona, and gentian was ordered to be taken for a fortnight,
and the patient was discharged from hospital.

“ At that time the patient was nauseated at the thought,
sight, or smell of whisky, and this condition has continued
up to the present time — a matter of nine mpnths. Since
this treatment, according to his own testimony and that of his
superiors, he has not touched a drop of liquor of any kind; his
former habits and inclinations appear to be broken off and the
cure to be complete.

“ The cure is, of course, due to suggestion and the association
of ideas combined with whatever tonic and anti-alcoholic
properties may be possessed by strychnine. The method here
employed, although empirical, has certainly brought about an
unexpectedly successful result in an especially unpromising
case, and it would seem as if this method, in selected cases, were
worthy of a more extended trial.”

The third report I shall read is one that was published
several years ago in the Medical News , by Dr. George E.
Bushnell, Assistant Surgeon, U. S. Army, then stationed at

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Treatment of Alcoholism.

Fort McKinney, Wyoming, and is entitled “ The Treatment
of Chronic Alcoholism by Hypnotic Suggestions.”

It may be stated that all treatments of the alcoholic habit,
even those of the writers of the reports I have already read,
have depended more or less upon the imagination and the
influence over the mind for their success, but, in this report,
hypnotic suggestion is alone relied upon as the therapeutic
agent.

I happen to know Dr. Bushnell intimately, and know him
to be one of the most modest and conservative men possible.
He worked over this subject of the treatment of chronic alco¬
holism by hypnotic suggestion for several years before ven¬
turing to publish his views.

I shall abbreviate his report, as it is somewhat longer than
there is time for me to read in full, leaving out the detailed
reports of cases which he gives. You will see that the Doctor
does not make any extravagant claims for the success of his
treatment, but simply reports the facts for the consideration
of the profession. What he says is sufficient to show, it seems
to me, that there is a certain power in hypnotism as applied to
treatment of the drink habit, which can, in selected cases, be
relied upon with success.

Abstract of Dr. Bushnell’s Report.

“ The treatment of chronic alcoholism has of late become a
matter of especial interest to the medical profession of this
country in view of the popularity of various secret ‘ cures ’ for
that condition. Ho unprejudiced observer can deny that these
methods of treatment have cured some drunkards of their
addiction to liquor for periods of some years at least. Al¬
though such so-called 6 specific ? treatments have been re¬
peatedly denounced by the medical press, it is a fact that many
physicians send patients to the institutions in which such treat¬
ment is given, or have adopted or attempted to imitate their
medicines. It appears to be generally admitted that strychnine

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and atropine are the active drugs in these secret compounds,
and we may well inquire whether the success of such treat¬
ment is or is not due to these alkaloids. During the past
three years I have experimented with hypnotic suggestion
in the treatment of chronic alcoholism and have obtained re¬
sults practically identical with those reached by these methods,
but, in the great majority of cases, in less time and without
giving a drop of medicine of any kind. It is, therefore, a
fair inference that in the methods of ‘ specific * cure the
psychic effect produced by the frequently-repeated hypoder¬
mic injections, by the symptoms arising from physiologic
doses of powerful alkaloids, and by the expectant attention
of the hopeful patient, is of more importance than the charac¬
ter of the drugs employed. It is true that th6 hypodermic
administration of the nitrate of strychnine was recommended
by Russian physicians in the treatment of alcoholism before
Keeley became known to fame, yet, it is to be noted that Dr.
Korona, of Tiflis, who has had a very large experience with
this method, raises the question whether its effect may not be
largely due to suggestion. This question can only be answered
by the experiment, which has never been tried, so far as I
know, of treating an alcoholic subject with hypodermic in¬
jections of strychnine, without allowing him to suspect that the
object is the cure of his appetite for liquor. But even if
strychnine, alone or in combination be granted to exert a
specific influence upon the liquor habit, as the tendency of
alcohol is to produce fatty degeneration, the use of so power¬
ful a cardiac stimulant as strychnine is not without danger of
causing the sudden death of the patient from over-excitation
of a fatty heart. This fact is recognized in the Keeley insti¬
tutes. A careful examination is made of the heart of all
applicants, and those are refused treatment in whom there
is any reason to suspect the existence of this degeneration,
thus excluding a class which most urgently needs deliverance
from the liquor habit.

“ The hypnotic treatment of alcoholism appears to be
little known in this country. I have been obliged to work
without much assistance from the literature on the subject,
which is for the most part not easily accessible, and the views
which I shall present are almost wholly the result of my own
experience.

Vol. XVIII—58

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Treatment of Alcoholism .

“ The following is a condensed report of all the cases of
chronic alcoholism which I have treated by hypnotic sug¬
gestion:

“ Excluding one case on account of inadequate treatment,
two cases because of the death of the patients, and one case
because the result is not known, there remains a series of nine¬
teen cases, which may be classified as follows:

“ 1. Remained abstinent to the present time or when last
heard from, 8.

“ 2. Relapsed and abstinent after further treatment, hyp¬
notic or ‘ specific/ 3.

“ 3. Relapsed after passing out of reach, 2.

“ 4. Relapsed and sought no further treatment, 3.

“ 5. Relapsed and continued to drink, notwithstanding
additional treatment, 3.

“ It may be fairly claimed that all of the patients were
sufficiently influenced by the treatment to have become con¬
vinced that they could be cured by a continuance of it. It
is, therefore, safe to assume for all the patients of class 4,
which I know to be true of one, that conviviality has pleasures
for them which they have found themselves unwilling to fore¬
go. The patients in class 5 were all non-commissioned officers
who were induced by their company commanders to submit
to the treatment, and, with the exception of one, in the early
part of his treatment, were not themselves desirous of help.
These men are restricted by their rank: to a narrow circle of
intimate friends, who are for the most part drinking men, and
total abstinence means for them the loss of almost all social
pleasure. The conspicuously bad result in their cases shows
well the futility of attempting such reform without the hearty
co-operation of the subject. Suggestive treatment can only
be expected to remove the physical cravings for alcohol. But,
unfortunately, after such cravings have disappeared) many
motives for the indulgence still remain, such as the influence
of associates, fondness for excitement and conviviality, and
the desire to forget trouble or disgrace.

“ In estimating the results here reported it should be
borne in mind that the frontier is the most unfavorable place
for the cure of alcoholism, on account of the almost universal
use of alcoholic beverages by the population and the lack of
innocent amusements. .

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“ I have never failed to hypnotize a patient who sought
treatment for alcoholism. Of the 23 cases here reported 18
were hypnotized on the first attempt, 3 on the, second, 1 on the
third, and one on the fifth.

“ The method which I generally pursue is as follows:
The patient, who is comfortably seated, is directed to fix his
gaze and his attention upon some object before him. It is
not necessary that this object should be bright, nor that it be
placed so near as to strain the accommodation or cause
marked convergence of the optic axes. In the meanwhile,
standing behind the patient, I stroke his forehead gently and
evenly with both hands. In the great majority of cases the
patient’s eyes close spontaneously in from two to ten minutes.
In some cases the patient is on the point of being hypnotized
but the eyes remain open, and must be closed before hypnosis
is induced. These cases may be recognized by the fixity of
the Hds. The patient does not wink, or, if winking is still
performed, the act is incomplete, the upper lid does not fall so
as to completely cover the eyeball. A more effectual, but
more disagreeable way of hypnotizing, is to sit facing the
patient and look him in the eye, the patient being charged to
fix his eyes steadily upon one of the eyes of the physician,
which are brought within a foot or two of his own. The
psychic effect upon the patient is greater than if he were
looking at the inanimate object, and his attention is conse¬
quently more easily concentrated. The physician relaxes
his accommodation to escape the eye-strain, which would other¬
wise be incurred. The eye-muscles of the patient are neces¬
sarily strained by this method, but the pain, and, in a great
measure, the conjunctival injection may be removed by sug¬
gestions during the succeeding hypnosis. Verbal suggestions
may advantageously be employed in connection with either of
these methods. If the patient is not hypnotized in fifteen
minutes it is, as a rule, best not to persist in the attempt to in¬
fluence him at that sitting. The second attempt will almost
always be successful. Hypnosis being induced, suggestions
are given to the effect that the patient will have no craving for
liquor; that it will be disagreeable to the taste and unpleasant
in its effects; that sleep, appetite, and digestion will be good;
that nervousness will disappear, etc. It is well to suggest that
there will be no nervousness, no pain in the eyes, and no head¬
ache upon awakening, also especially in the case of those who
are hypnotized with difficulty that there will be no drowsiness.

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Treatment of Alcoholism .

“ The ease with which patients fall asleep increases gen¬
erally at each repetition of the hypnosis within certain limits.
That intoxication predisposes to hypnosis is shown, however, by
the fact that a patient who has been hypnotized in two minutes,
while under the influence of liquor, often requires three or four
times as many minutes to produce that result after he has be¬
come perfectly sober.

“ The treatments are repeated, if possible, every day for
at least a week, after which they are given once a week for a
few weeks, then once a month. The number of treatments
necessarily must be determined separately for each case, as
there are great differences in the individual reaction to sug¬
gestion. I have allowed the worst drunkards to continue to
drink during the early part of their treatment, with the re¬
striction that they take no more liquor than is necessary to pre¬
vent nervousness and sleeplessness. This concession saves the
patient some suffering, and the effect upon his imagination is,
perhaps, greater if he is convinced by actual trial that liquor is
becoming more and more unpleasant in its taste and its ef¬
fects. From three to six treatments generally suffice to re¬
move the craving for alcoholic stimulants in those who ab¬
stain. In those who continue to drink, the effect of the treat¬
ment always manifests itself in a rapid loss of the acquired tol¬
erance for liquor, which becomes more intoxicating, and at
the same time more disagreeable, until a point is reached, gen¬
erally after from five to seven treatments, when it appears to
the patient that a sudden change takes place in his appetite.
He can often state the exact hour when 6 the whisky turned on
him/ as he is apt to express it. This change he considers so
profound and permanent that there is often difficulty in in¬
ducing him to return for what appears to him unnecessary ad¬
ditional treatment.

“ It is an interesting fact that, while it is easy to render
whisky repugnant to the senses of the patient, it appears to
be impossible to accomplish this in the case of beer by any num¬
ber of suggestions. The loss of tolerance and the cessation of
cravings for alcohol are reached, however, with as great cer¬
tainty in the one class of drinkers as in the other.

“ It might be expected that patients would attempt to ex¬
cuse themselves in case of relapse by alleging the return of
irresistible cravings for liquor. This has occurred in none of
my cases, except one, under circumstances already detailed.

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The difficulty is almost always the temptations of conviviality,
unwillingness to offend by refusing ‘ treats/ and the like. In
the least successful cases, the first taste of alcohol reawakens
the former cravings. The majority resume their old habits
more gradually, and the whisky drinker will sometimes drink
beer for a considerable period without excess. But in all
cases the continued indulgence in drink leads certainly and
generally speedily to drunkenness. The relapsed drunkard
finds that he has no longer the ability to ‘ carry 9 liquor upon
which he once prided himself. If he does not. recognize and
respect that fact, he is in danger of the deepest intoxication.

“ The evil effects of alcohol upon the nervous system are
marked in cases that have been treated by suggestion, and de-
lirum tremens may result from comparatively slight excess.
It is perhaps unnecessary to say that this loss of tolerance of al¬
cohol is due simply to the character of the hypnotic suggestions
which have been employed. Hypnotism may be used to pro¬
duce the opposite effect.

“ Suggestions, the effects of which are not intended to
persist, should be avoided. It is not necessary to attempt to
impress the imagination of the patient by varied suggestions,
the purpose of which simply is to Show the power of the physi¬
cian over him. Nor is it necessary for the treatment of the
great majority of cases that the subject be in the so-called
‘suggestable stage’ of hypnosis. Functions which are not
directly under the control of the will, such as sleep, peristalsis,
the appetites, natural and artificial pain, the organic sensa¬
tions, etc., may be influenced by suggestion in any stage of
hypnosis from the slightest drowsiness to the deepest sleep.
Even a considerable degree of intoxication is no barrier to the
success of such suggestion, as I have repeatedly observed.

“ Hypnotism is not necessarily exhausting to the patient, as
has been claimed. On the contrary, if his nervous energy is
not wasted by suggestions which produce fatigue or disgust,
he feels refreshed upon awakening, as from ordinary sleep.
The dangers of hypnotism, as far as they exist elsewhere than
in the imagination of its opponents, are due almost always to
an Improper use of the method. Certainly as employed for
the cure of alcoholism there are no dangers to be feared from
it which are at all comparable with those arising from a con¬
tinuance in habits of intemperance.”

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Treatment of Alcoholism .

Appendix. Extracts from Annual Report of the Surgeon-
General of the Army for 1895.

Captain W. H. Arthur (Assistant Surgeon, XL S. Army)
reduced the statistics of alcoholism at Vancouver Barracks by
dealing with drunkenness as with acute poisoning. He reported
as follows:

“ The report of the Surgeon-General for the year ended
June 30, 1892, mentions this post as having out of all the
army the highest rate of admission to sick report for alcohol¬
ism. The number of cases of simple acute alcoholism that
appeared at sick call, and during the day, when I first assumed
charge of this hospital, was unusually large, and resulted in
the laying down of certain rules in an effort to discourage drunk¬
enness as far as it was in my power. No man is taken on the
sick report or excused from any duty unless, in my opinion,
his condition would make it actually dangerous for him to keep
at work. I may say here that such cases are, in my experience,
very rare, and that a mistaken pity for a man suffering from
the effects of a debauch is liable very often to lead a too indul¬
gent post-surgeon to excuse him from duty, when the guard¬
house, and not the hospital, is the proper place for him. I am
confident that this mistaken kindness has done a great deal in
the past to encourage drunkenness. Each man who has re¬
ported at the hospital in any stage of simple alcoholism is
treated as a case of alcoholic poisoning, taken immediately to
the operating room, his stomach emptied by the use of the
stomach-pump, and thoroughly washed out with warm 2 per
cent, soda solution. After this he is given a bowl of hot beef
extract, with cayenne pepper, allowed an hour’s rest, after
which he is generally perfectly able, however unwilling, to do
his duty. If the weather is severe, either very hot or very
cold, it might not be safe, in his depressed condition, to force
a man to work out of doors immediately after this procedure,
but at this post the extremes are not great, and it has in no
case resulted prejudicially to the patient. Occasionally some
resistance is met with, but two, or at most three, able-bodied
hospital corps men and a perforated wooden gag, such as comes
with the stomach-pump, will, with patience and determination,
overcome almost any ordinary opposition. I have found for
this purpose the gum elastic stomach tube in the old-fashioned
stomach-pump case, connected with Allen’s surgical pump

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work, very satisfactory. The ordinary soft rubber lavage tube
is too easily collapsed, and is more difficult to introduce when
there is resistance.

“ The effect of this treatment has been uniformly excellent.
The stomach, emptied of its irritating contents, and cleansed
of the thick, tenacious mucus that is always present in such
cases, is much less irritable, and rarely rejects the beef extract
which is given immediately; the nervous symptoms improve at
once, and sedatives administered by the mouth have a far more
prompt and lasting effect, and, in almost all cases, the craving
for liquor is very much diminished. Of course cases may oc¬
cur which are too serious for such summary treatment. I have
not met with any myself, and have used the stomach-pump
with good effect in cases even of delirium tremens and alcoholic
coma. These cases, of course, are promptly taken into the
hospital and treated as dangerously sick men. The deterrent
effect of this treatment is excellent. It is, of course, not agree¬
able, though no one can deny that it is perfectly rational and
merciful. In the past ten months but one man has been ad¬
mitted to hospital for alcoholism. There are no doubt other
factors that enter into the production of this marked change
the post in two years, but I am confident that this method
of treating alcoholism as poisoning has been a very important
if not the principal one. I may add that in but one case has
it been necessary to use this treatment on the same man more
than once.”

Judge Parker, in the North American Rcvieiv, says that
during twenty-five years of service a thousand persons have
come before him accused of murder. At least three-fourths
of all these cases were due to the use of spirits. He believes
that nearly all cases of murder are in some way associated
with the use of spirits. In twenty-six murders, in one section
of the country, twenty-five were due to the use of alcohol.
These cases occured in Arkansas and the Indian Territory, in
the federal court.

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Abstracts and Reviews.

ki\d f^eview^.

THE RELATIONS OF ALCOHOLIC INDUL¬
GENCE TO INSANITY.

The influence of the excessive use of alcohol in the pro¬
duction of insanity is one of the certainties, and yet there is
occasionally a question raised as to the relative importance
of this casual factor. A few years ago a physician, since a
superintendent of one of our large state asylums, wrote
a paper to show that its effects were insignificant, and in one
way or another there has been produced a considerable liter¬
ature on this side of the question. Nevertheless it may be
fairly assumed that alcoholic intemperance is generally ad¬
mitted to be a very important, if indeed not actually the most
important, cause of mental disorder. Those who would dis¬
pute it are comparatively insignificant in number among
alienists, and there is not any preponderance of scientific
authority against it. •

There are, however, certain questions that arise in this
connection that are not so readily disposed of. While it is
admitted that alcoholic excesses tend to mental break-down,
while acute and chronic alcoholism are disorders that are
universally recognized as appertaining more or less to the
specialty of psychiatricial medicine, there is yet room for a
wide difference of opinion as to the effect of the use of alco¬
holic drinks in what is called moderation. There is certainly
enough excess to produce a very large percentage of insanity
in our asylums, but data are too generally insufficient for us
to be able to say with exactness the proportion of cases in
which it has certainly been an etiological factor. These are
by no means always what would be classed as cases of alco¬
holic insanity, as we are well aware, and often there may be
nothing in the history as well as in. the symptoms to point

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377

directly to any such origin. Intemperance is a disreputable
fact and is likely to be concealed or denied, even when it
may have been excessive. It is very possible, that this ten¬
dency far overbalances the contrary one of making erroneous
post hoc , ergo propter hoc , diagnoses of insanity from alcohol¬
ism on account of prior known habits when really other
causes are to blame, in asylum statistics, and that our figures
of mental diseases of alcoholic origin are much below, rather
than above, the truth.

The questions, therefore, that arise as regards the influ¬
ence of alcohol in the production of insanity may be stated
as follows :

1. Does alcoholic excess produce insanity ? This, as
already stated, may be regarded as an indisputable fact.

2 . In what proportion of cases is this factor to be ad¬
mitted ? This is one to which various answers have been
made, as indicated. The majority of reliable authorities
place the percentage of cases directly due to this cause at
not less than io or 12 per cent.; some recent writers have
estimated it much higher, and consider the increase of in¬
sanity in modern times as very largely due to such excesses.
This is the view held by Smith, of Marbach, in a paper
read last November before the Southwestern German So¬
ciety of Alienists, and Gamier, of Paris, in a communication
a year or two ago, claimed that insanity had increased 30
per cent, in the last fifteen years in that metropolis, largely
from this cause, and that alcoholic insanity, properly so-
called, had increased in that period threefold. Those who
have minified the influence of intemperance to producing be¬
low 10 per cent, are very few and include no recent high
authorities. We may therefore safely assume that at least
10 per cent., and probably more, of the cases of insanity in
most civilized countries are directly due to alcoholic excesses.
If we include only males, the percentage will naturally be
higher, as alcoholic insanity is comparatively infrequent in
women, and if we admit it as an indirect cause, we must add
a considerable proportion of all cases of insanity in both

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sexes as more or less influenced by this factor. The poverty
and misery induced by intemperance, the impaired constitu¬
tions, the reckless exposures, the traumatisms, etc., will all
have to be considered. We might also add the defective or¬
ganization inherited by the children of drunkards under this
head to still further swell the percentage.

3 . What constitutes excess in the use of alcohol, and
what is the influence on the production of insanity, of what
is considered its non-excessive usage ? This is the most
complicated question of all, and the one that is hardest to
answer satisfactorily. The often quoted experimental in¬
vestigations of Anstie, Parkes, and Wollowicz, and of Du-
jardin Beaumetz, seems to show that, under normal condi¬
tions, between one and two ounces daily, or not much over
the latter figure, of absolute alcohol is about what an average
robust individual can stand, and that any amount above that
is beyond the danger limit, or more than the system can dis¬
pose of with safety. This, however, only applies to perfectly
healthy and normal individuals, and does not cover all the
possibilities of either tolerance or intolerance of alcohol.
We know very well that for almost all time some individuals
have been using intoxicants to a far greater extent than is
above indicated, without any very apparent directly damag¬
ing effects upon themselves, as far as known. On the other
hand, perhaps, a greater number will be seriously injured by
even less than the minimum here given. Moreover, the not
finding alcohol in the urine does not positively show that the
system is innocuously disposing of all that is injested; there
may be more or less injury to the nervous system, even
from a small amount. There is no class of agents that have
their effects more modified by individual idiosyncrasy than
stimulants, and of these alcohol probably takes the lead in this
respect. The same dose will affect one man in his brain,
another in his cord, and a third perhaps in neither. Steady
drinking will cause often the most opposite effects, both
physical and mental, according to the individual; with the
same kind and quantity one man is jovial, florid, and red

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379

nosed; another is pallid, taciturn, and surly ; one man is in¬
coordinate, with a comparatively clear head ; another has his
judgment and temper awry, without any apparent bodily
symptoms whatever.

As regards small amounts of pure alcohol, the same holds
true — there is no general universal standard of moderation.
When we consider, however, that it is seldom taken pure,
and that its physiological action is complicated by the other
more or less active constituents in the usual beverages, to
say nothing of the unknown adulterations, it will be seen
that the question is a very complex one. According to
Dujardin Beaumetz, bad brandy is more directly toxic than
absolute alcohol, and that is the character undoubtedly of a
large proportion of the drinks now commonly used by more
or less habitual drinkers.

The chief action of alcohol, however, is that which it
exerts upon the brain and nervous system, and it is for that
that it is used as a beverage by mankind ; whatever benefit
it may be as a food, a retarder of tissue waste, or an assistant
to digestion, is a very secondary matter, and is not usually
regarded by the drinker except as a convenient excuse for
the indulgence. It would not be unnatural to suppose that a
normal brain has no need of alcohol, and that the effects of
so active an agent on* one inclined in any way to be abnor¬
mal might be deleterious, and that in the way it is commonly
taken, with all its associated more or less active substances,
some of which are even more potent for evil than itself, this
would be still ntore likely to be the case. There is, there¬
fore, a reasonable doubt, at least, as to the safety to mental
health of even small continued doses of alcoholic drinks, and
the burden of proof lies on the side of those who would dis¬
pute this conclusion.

Practically there is no standard of moderation in the use-
of alcoholic drinks, and it is therefore impossible to use statis
tics to determine the effect of moderate drinking in the pro¬
duction of insanity. What would be moderation in one
would be excess in many more, and the statements of habit-

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ual drinkers cannot always be accepted as to their habits.
The only way actual statistics could be obtained would be
from the fullest and most carefully studied individual histo¬
ries, covering not only the facts of the life of the patient him¬
self, but also those of his ancestors for at least two or three
generations. Charcot is credited with saying that, “ every
drop of the seminal fluid of a drunkard contains the germ of
all the neuropathies.” This being so we will have, in order
to positively eliminate the agency, direct and remote, of
alcohol, to search the pedigrees and family histories to find
the neuropathic taint thus originating that may develop into
insanity, possibly of the alcoholic type, possibly in any other
form, in the descendant of the original transmitter. A
habitual user of alcohol may, it may be possibly admitted,
show no bad results in his own person and yet pass on a
deteriorated nervous constitution to his offspring. The
effects on the individual himself may be slow in develop¬
ing, and may require a skilled medical diagnosis for their
recognition as of alcoholic origin, however serious they may
be. It would be of interest to know what proportion of
cases of senile insanity and late organic dementia occur in
abstainers and in those who have been accustomed to the
occasional or habitual moderate use of alcoholic drinks, and
in this line is perhaps the best hope of finding any value in
statistics for answering this particular question. If moder¬
ate drinking has any effect in causing insanity, it might be
naturally supposed that it would be late rather than early in
its appearance.

It has been already mentioned that we have to consider
not merely the alcohol but the constituents of the ordinary
beverages when taking account of the pathological effects of
these latter. Pure alcohol is very little used as a beverage,
and when so used, as by the Scandinavians in some parts of
our country, it is nearly always to excess and the effects are
obvious and indisputable. In the ordinary spirituous liquors
we have not only ethylic, but also the higher, more toxic
alcohols in greater or less proportion, together with various

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381

ethers and other substances, many of which are powerful
neurotics, to say nothing of unknown adulterations that may
be more or less harmful. These last, together with the
ethers, etc., occur also in the various wines, especially the
imported ones. In beer we have had of late years a number
of new constituents, as there have been extensive changes
in its manufacture. Malt liquor would seem to be a mis¬
nomer for some of the beer of to day, as glucose is said to
have largely superseded malt in some beers, and where the
cereals are employed they are likely to be rice or corn (meal),
etc., instead of the traditional barley. Whether these
changes render the drink any worse as regards its action on
the nervous system may perhaps be a question, but is one the
consideration of which complicates the subject. The amount
of the nervous depressant lupulin with the alcohol taken into
the system is also worth bearing in mind in the consideration
of the possible effects of beer, in favoring insanity. A priori ,
it would seem that it might have such action, but as yet
actual satisfactory data are hard to obtain. That the moder
ate use of alcohol, generally in the form of beer, has a bad
effect in actual existing mental disease is supported by the
testimony of English (thirty out of fifty superintendents re¬
porting), German (Kraepelin), and Swiss (Forel) alienists
who have had experience with and without its usage.

The answer to the third question, therefore, is a compli¬
cated one. There is no exact standard of moderation in
drink; the maximum quantity is injurious to some, while
others are apparently unaffected injuriously by very large
amounts. If we could put all moderate drinkers on a certain
ration, really moderate and within the limit given by Parkes
and others, of alcoholic drinks, and keep them to it, and we
could after a time ascertain their physical personal equations
as to endurance of alcohol, some generalizations could be
made from statistics. Where this has been done, as, for ex¬
ample, in the population of some asylums in Europe, the
weight of evidence is rather against the absolute innocuous¬
ness of alcohol so used. The conditions there, however, are
not those of the average population, and cannot be accepted

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as applying directly to the question of the production of
insanity by alcohol.

There may also be some little value to statistics of
organic and senile insanities as occurring in known moderate
drinkers and in abstainers.

The answer to the question is complicated by the uncer¬
tainties as to the exact toxic value of the drinks used; the
other neurotic constituents besides the alcohol they contain;
by the effects of climate, age, individual idiosyncrasies, etc.;
by the possibilities of the late developments from long-con¬
tinued dosing and those of hereditary transmission, and
especially by the varying and often very liberal notions of
drinkers as to what moderation is, and the tendency of even
moderate drinking to lead to excess in individuals possessing
any neurotic or hereditary taint.

A priori , it would seem probable that even the moderate
use of powerful neurotic agencies would at least have no
beneficial effect on a normally constituted brain, and that in
one at all abnormal, when used simply as an indulgence and
not under any scientific medical supervision, there might be
serious chances of positive injury.

Our knowledge of the effects of alcohol in the production
of insanity may, therefore, be summed up as follows :

1. Alcoholic excesses produce insanity.

2 . They are directly the cause of at least io or 12 per
cent.,, and probably of a somewhat larger percentage. Indi¬
rectly they are among the casual factors of a very large pro¬
portion of cases that cannot be directly credited to alcohol.

3 . Moderate drinking is a very indefinite term, and this
fact alone makes it impossible to utilize satisfactorily any
statistics as to its effect in producing mental disease. There
is, however, no reason to believe that moderate indulgence
in alcohol is specially conducive to mental health in the
average individual, and there is, on the other hand, a certain
amount of physiological a priori presumption to the contrary.
For the victim of hereditary taint or the neurotic it is
undoubtedly often disastrous in its effects in this direction.
— H. M. Bannister, M.D., and Alder Blumer, M.D., in
American Journal of Insanity.

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383

CONSTIPATION IN CASES OF TEA-POISONING
AND INEBRIETY.

Dr. Wood, in the Brooklyn Medical Journal> says that the
plan which was found to give the best results was to com¬
mence by interdicting the use of tea, coffee, or any form of
liquor. This must be insisted upon in the strongest manner,
else the patients, like all inebriates, will be found indulging
their annoying importunities for tea.

The alimentary canal should be thoroughly cleared out
by giving a rather large dose of calomel and jalap (8 grains
of each) at night, to be followed in the morning by Rochelle
or Epsom salts (i£ ounces). This will assure an almost
completely empty intestine and the absence of fermenting
material, which, in a large majority of cases, produces a
true auto-intoxication. The patient should be kept on hot
milk for several days, the only medication being 4 grains of
caffeine and 8 grains of sodium bromide every four hours.
This quiets the irritable nervous condition, and the limited
food gives nature an opportunity to regain lost tone.

The use of cascara sagrada is commenced at this time,
the dose being from 15 to 40 minims every four hours.
From the third to the tenth day the patient's diet is in¬
creased to the proper amount as demanded by the work
performed, care being taken to eliminate such stimulating
and non-nutritious articles as the starch and sugars, so far as
possible.

The dose of cascara sagrada mentioned above may be
increased and the time for giving it lengthened until the
patient’s bowels will move freely at least once a day by the
employment of from % to 1 drachm at night.

In a number of cases, when this regularity has been
observed, the following prescription will be found of great

USe :— Inspissated ox bile, pure, 3ii;

Sulphate of quinine, 3i;

Sulphate of strychnine, gr. i;

Extract of cascara sagrada, 3i;

Extract of euonymus, 9ii;

Extract of gentian, q. s.

Divide into forty capsules; 2 are used morning and night.

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The inspissated fel bovis prevents to a large degree
intestinal decomposition, accelerates peristaltic action, im¬
proves the intestinal digestion, and increases and hastens
absorption. In being taken up by the liver it furnishes a
fresh impulse and available material for the formation of new
bile. The strychnine serves as a bitter tonic and a stimu¬
lant to the spinal centers, and the nerves of the splenic arcade
and, in turn, the glands which they supply resume their
former activity. The euonymus is a cholagogue cathartic
and stimulates the liver to secrete a better quality of bile.
Enough of the cascara is used with the euonymus to assure
a good passage from the bowels daily.

In a number of cases Fowler’s solution is given so soon
as the bowels are moving daily, and often with excellent
results. The preparation of cascara which is given the pref¬
erence over all others is the aromatic fluid extract or elixir.
This palatable method of giving the drug should be resorted
to whenever it can possibly be secured, and many patients
who are in a neurasthenic and hysterical condition and have
a horror of all medicines will offer little objection to this
preparation.

The nerves of the alimentary canal during tea intoxica¬
tion are in a torpid condition from over-excitation, and the
secretions of the glands have been very much reduced by the
large amount of tannic acid in the tea infusion. No drug
has yet been found which will so well restore the lost tone of
the debilitated gut and increase the secretion and peristaltic
action as cascara. The action of the drug on the bowels
is not sudden; the more sudden acting cathartics, in the
author’s hands at least, have proved harmful. What is clearly
indicated is a tonic laxative which will at the same time in¬
crease the action and secretion of the gastric, intestinal, and
biliary organs.

In cases of constipation of short juration the capsule
above given is not used, but dependence is entirely on the
cascara. Is has been found eminently satisfactory. In those
cases where the intoxication has extended over a number of

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385

years other medicinal agents must be added which will re¬
store the lost bodily tone and correct functional perversion.

Treatment should not be stopped as soon as the patients
feel better; in many cases it must be continued for several
weeks. After the digestive troubles have been overcome
and the system shows a tendency to establish an equipoise of
health, a tonic pill is used for a considerable time. The con¬
stituents may be arranged to suit the advancement made.
It is as follows : —

Sulphate of strychnine, gr. i;

Hydrochlorate of caffeine,

Extract of damiana, of each, 3i;

Hydrochlorate of cocaine, 3i;

Extract of taraxacum, 3ss.

Divide into twenty pills, of which one should be given twice daily.

This excellent formula was used by Professor Porter of
New York, with the ipost gratifying results, as a stimulating
restorative in all complaints which had associated with them
loss of bodily tone. The caffeine and damiana are nutritive
tonics of no mean ability to the cerebro-spinal centers and
the motor nerves which supply the splenic arcade. The
cocaine is only added in those cases where the hyperaesthesia
of the solar plexus produces the sinking sensation in the pit
of the stomach which is much complained of. By this pro¬
cedure permanent relief can be given to the truly deplorable
condition of by no means a rare class of patients.

INEBRIETY A DEFENSE FOR CRIME.

Dr. Norbury, the eminent editor of the Medical Fort¬
nightly, in a recent editorial remarks as follows: Since the
days of Spartan lawgivers, it has been held that drunkenness
is no excuse for crime ; in fact many judges hold it is but an
aggravation of a criminal act. Jurisprudence has been slow
to accept the teachings of the disease theory of inebriety,
and excepting in delirium tremens has never recognized such

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a plea. In criminal relations the law seems more harsh in
its practical application, than in civil or social relations.
That this is but just is evident, when objectively we con¬
sider that the drinking man can voluntarily place himself in
a position to do criminal acts. Many courts hold that intox¬
ication, irrespective of degree and its effects, does not alter,
modify, or excuse the act. Again, the rulings of the courts
as to the mental unsoundness growing out of voluntary in¬
toxication, occurring in a person previously sane, do not
alter, modify, or excuse the act, or, more carefully stated, from
acts committed by him in violation of law while in that
state. (Not less than twenty decisions are cited in this
country on this point alone.) However, one familiar with
the clinical aspect of mental unsoundness, primarily or sec¬
ondarily due to inebriety, knows that there are phases of the
disease which demand a thorough investigation, ere such a
ruling be declared. The law holds that there must be a
motive and intention to constitute crime, and this should be
a modifying factor, even in diagnosis, inasmuch as uncon¬
scious acts committed during the suspension of memory, in
themselves indicate incapacity to act from motive. Again, it
is proper that inquiry be made as to whether the accused
was in a condition of mind to be capable of premeditation.
Again, to formulate the diagnosis, it is necessary that all
the circumstances attending the intoxication be considered ;
whether or not he voluntarily placed himself in such a posi¬
tion so as to commit crime; so as to use drunkenness for a
defense; simulation of mental unsoundness is not unheard
of under such conditions.

But there are conditions of mental impairment, recog¬
nized by alienists, which indicate a diseased mind, and as
such relieve responsibility, and place the crime, where it be¬
longs, under the head of insane acts. It is, or should be,
held that such evidence of mental unsoundness growing out
of intoxication should be admitted to explain the conduct
and intent of the accused, especially in homicide. There are
certain other conditions to be investigated in the study of

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such a case, the chief of which is the existence of certain
constitutional or specific diseases, which affect both the
brain and nervous system, and which do modify the effects
of alcohol, even when taken by a person previously sane.
Such a specific disease (syphilis for instance) may in itself
be the primary cause of the mental unsoundness, and intoxi¬
cation merely a secondary phenomenon.

Again, heredity is a factor, the individual being endowed
from birth with what is termed a narcotic diathesis, that is
a precocious sensitivity to narcotics, whereby a defective
nervous and mental organism results, which is evident by a
loss of inhibitory power, thus making it extremely difficult
for the individual to resist the potent influence of alcohol.
Further, this sensitivity may be acquired, as is noticed from
the influence which the before mentioned specific diseases
have upon the nervous and mental organism. It is this class
(both the hereditary and acquired) from which spring the
cases in which it is not only justifiable, but scientifically cor¬
rect, that a defense of mental unsoundness be made — the
marked forms of the unsoundness of mind being delirium
tremens and “ mania-a-potu.” During the continuance of
either the patient is undoubtedly insane, he being quite
unconscious of his actions, dead to all perception of right
and wrong, and incapable of reasoning.

There are other forms of inebriety wholly within the do¬
main of the disease, chief of which is dipsomania, a disease
in which the periodical outbreaks of intoxication are uncon¬
trollable— a blind, irresistible impulse to seek excessive in¬
dulgence in alcohol exists, and is not overcome by reason,
will, or the thought of disgrace, family pride, etc. This form
is often found in some of our most useful citizens—men of
letters, culture, of refined tastes and manners, and who drink
because they are impelled to it, and not for social pleasure.
A medico-legal inquiry into such a case will always place
the individual as a sick man — unsound mentally during his
spree, and hence irresponsible. To this class belong the
individuals wherein are found those freaks of unconscious-

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ness, the most interesting of which is so-called “unconscious
cerebration/* characterized by the patient doing acts auto¬
matically, yet being without knowledge of his actual condi¬
tion, at the same time appearing to be acting naturally.
Such persons wander away from home, even remain away
for months, engage in occupations entirely dissimilar to their
previous occupations, and some day awaken to find them¬
selves among strangers; all of this time they have no recol¬
lection of what they have been doing, the interval between
the commencement of their attack and the return to con¬
sciousness being a complete blank. This cerebral automa¬
tism I have seen and know it to be possible. Medico-legal
literature has recorded a number of such cases. Now, as to
the application of these facts to the study of responsibility,
this is the function of the lawyer and the judge ; medicine
merely states the facts, the law applies them. No case can
be decided wholly upon its merits — it requires the patient
study of all circumstances, and especially the function of
diagnosis. That public opinion does sway the decision of a
jury is a probability with some foundation, but upon the
whole it is my belief, that a jury can, and will in the great
majority of cases, be able to sift facts, from fancies or preju¬
dices, and weave something tangible from the confusion
occasioned by expert testimony, which, alas, is as yet no
credit either to medicine or law, and let ‘'justice be done,
though the heavens fall.”

INTOXICATED WASPS.

Concerning his observations of wasps which are addicted
to the use of intoxicating liquors, Lawson Tait relates the
following:

“ I have been watching the wasps with great interest and
have noticed the avidity with which they attack certain fruit
when fully ripe, rotting in fact, and I have also noticed some
of the peculiar results of their doing so. The sugar in some

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389

fruits which are most attacked by wasps has a tendency to
pass into a kind or kinds of alcohol in the ordinary process
of rotting, a fact which is easily ascertained by the use of a
still not large enough to attract the attention of the excise
authorities. On such fruits, particularly grapes and certain
plums, you will see wasps pushing and fighting in numbers
much larger than can be accommodated, and you will see
them get very drunk, crawl away in a semi-somnolent condi¬
tion, and repose in the grass for some time, till they get over
the ‘bout/ and then they will go at it again. It is while they
are thus affected that they do their worst stinging, both in
the virulent nature of the stroke and the utterly unprovoked
assaults of which they are guilty. I was stung last year by
a drunken wasp, and suffered severely from symptoms of
nerve poison for several days. In such drunken peculiari¬
ties they resemble their human contemporaries. ,, — Regis¬
tered Pharmacist .

CHLORIDE OF SODIUM INEBRIETY.

Dr. Woodward in the Eclectic Medical Journal writes as
follows :

It is estimated that we daily consume about one hun¬
dred and forty grains of salt, which the author concludes is
entirely too much. Persons who have eaten from one to
three drams of salt daily for years are affected by several of
the following symptoms:

1. A thickened and partial paralysis of the vocal cords,
and an almost continual sore throat.

2. A pale and waxy color. A dryness of the cuticle,
which perspires too freely upon exertion.

3. Constipation.

4. Chronic diarrhoea.

5. Abnormal appetite.

6. Retarded endosmosis and exosmosis,

7. Plethora and corpulency.

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Abstracts and Reviews .

8. Thins the blood, causes slow circulation, and lowers
the temperature.

9. Increases catarrh and prevents its cure.

10. Causes dandruff on the scalp.

11. Causes skin diseases.

12. Causes deposits and abscesses.

A number of cases are given with one or more of the
above conditions predominant. In all the salt was restricted
and depurating medicines given with good results.

In catarrhal diseases, the use of salt aggravated the
symptoms ; removing it effected a cure. The reason given
is that the skin not acting, from the effect of the salt, the
mucous membrane had to perform an extra function, hence
the discomfort. Removing the cause cured the disease. It is
stated that acrobats eschew salt; that the Parisians, twenty
years ago, deprived inebriates of salt. In six months all
taste for liquor was gone.

HEREDITARY INEBRIETY.

The editor of the Temperance Record , in a review of
Lunacy Commissioners’ Report, closes in the following signifi¬
cant words:

“ A careful consideration of the subject of hereditary ine¬
briety enables us the better to understand the significance of the
figures we find in the Lunacy Commissioners’ Report. Table
22 shows us that intemperance was the predisposing or ex¬
citing cause of the insanity in the case of 20.9 per cent, of all
the males, and 8.1 per cent, of all the females admitted.
Taking the general paralytics among the insane, intemperance
was the assigned cause in 25 per cent, of the males, and in

18.8 per cent, of the females; and in the case of insane patients
with suicidal propensity, intemperance was accountable for

20.9 per cent, of the males, and 7.3 per cent, of the females.

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391

But the commissioners state in their report that ‘ hereditary
influence again figures as the most potent factor in the pro¬
duction of insanity/ and the figures in the table inform us
that it was accountable for the insanity of an annual average
of 1,749 of the males, and 2,254 of the females who were ad¬
mitted during the years 1890 to 1894, or 21.1 per cent, of the
males, and 25.6 per cent, of the females. The diseased organi¬
zation produced by intemperance does not always develop in
the offspring a craving for drink. The drink-produced de¬
generacy takes other forms. But whatever the defects and
tendencies drunken parents transmit to their offspring they
are all in the direction of insanity — to which intemperance
has in many respects so close a resemblance, with which it has
such an intimate alliance, and to which it so frequently directly
leads. And it is not to be doubted that in the case of a large
proportion of the patients whose insanity is attributed to
‘ hereditary influence/ intemperance was the source of that
influence towards insanity which is now recognized as heredi¬
tary. Looking down the list of ‘ causes of insanity/ we come
upon ‘ previous attacks 9 as accountable for the insanity in
16.0 per cent, of the males, and 21.7 per cent, of the females;
and upon 6 unknown ’ as applicable to 18.8 per cent, of the
males, and 16.6 per cent, of the females; and we maintain that
there is every probability of intemperance being a considerable
factor in these large proportions. If we attribute to intem¬
perance no more than one-half of those who are reported insane
under ‘ hereditary influence/ and one-fourth of the * previous
attacks ’ and the 6 unknown/ we discover that of the males
who find their way into asylums for the insane about 40 per
cent, get there through drink, and of the females about 30
per cent. This means a large, but little considered, addition
to our enormous drink bill; and who can tell what it means
to the individual victims and to the family circles they taint,
and whose happiness they destroy? ”

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Abstracts and Reviews .

The Homiletic Review gives a scholarly, clear presenta¬
tion of the current thought in theological circles. Unlike
the older literature, which was obscure and doctrinal, this
journal gives a graphic, popular setting to the modern thought
of religion. No better present could be made than a year’s
subscription. Write Funk & Wagnalls, New York city,
publishers.

The Hypnotic Magazine , published by the Psychic Pub¬
lishing Company at Chicago, Ill. This is devoted exclusively
to hypnotism, its uses, and therapeutical possibilities. The
August and September numbers contain some very suggestive
papers of great practical interest. This study is clearly a very
large one, and no doubt, in the near future, will bring to
light remedial forces almost unknown at present. This is
a very interesting magazine, and we heartily commend it.

The half-century of the publication of the Scientific
American is celebrated in an anniversary number of great
excellence and value. Keviews of the progress and history
of many of the most wonderful inventions are given in a con¬
densed form. This is literally one of the most valuable group¬
ing of facts concerning these new discoveries which has ap¬
peared. This nuitiber in particular, and the journal as a
weekly periodical, is unrivaled among the scientific publica¬
tions of the day.

Moodies Magazine of Medicine , edited by Dr. Bell, and
published at Atlanta, Ga., has made a very successful start to
combine literature and medicine, and thus to reach the physi¬
cian’s family and associates. There is, no doubt, a vacant
place in medical literature along this line which skill and
genius can fill. Dr. Bell has an open field and no rivals in
sight, but an ever-increasing crowd of admirers will welcome
every issue of this new effort, and rejoice at its success. Send
for a copy of this venture in medical journalism.

Some Physiological Factors of the Neuroses of Child¬
hood. By B. K. Bachford, M.D., Professor of Physiology

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Abstracts and Reviews .

393

and Clinician to the Children’s Clinic, Medical College of
Ohio; member of the Association of American Physicians and
of the American Pediatric Society, etc. Cincinnati: The
Robert Clarke Co., 1895. This little work of a hundred and
twenty pages should be read by every practical physician. In
a clear concise style the author gives a very suggestive study
of the following topics: “ The Normal Functions of Nerve
Cells,” “ The Physiological Peculiarities of the Nervous Sys¬
tem of Infancy and Childhood,” “ Fever and the Variable
Temperatures of Childhood,” “ Heat-Dissipating Mechanism,”
“ Autogenetic and Bacterial Toxines,” “ Venous Condition of
the Blood,” “ An Impoverished Condition of the Blood,”
“ Reflex Irritation,” and “ Excessive Nerve Activity.” In
connection with studies of the early causes of inebriety this
work brings out many facts not well known, and will be found
of great value to students in this field.

The leading citizens of Cape Town, Africa, have petitioned
the colonial secretary to establish an asylum for inebriates.
The secretary has expressed his warm support of this move¬
ment and promised that the government will aid it in every
way. A bill has been prepared appropriating money and
making laws for control, which will be presented at the next
Parliament.

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Editorial

^ditorikl.

SUBJECTIVE AMNESIA IN INEBRIETY.

Defects of memory are very common in inebriety, but
usually they do not attract much attention. Alcoholic blanks,
called trance states, in which the person moves about ap¬
parently acting with a normal consciousness of his conduct
and all the surroundings, but literally is in a somnambulistic
state, have been studied in their medico-legal relations.

While these extreme cases are now recognized in many
instances, periodical, acute, and partial amnesias are practically
unknown. A blank of memory during the period of intoxica¬
tion will clear up after a few days, and events be fairly clear
which happened during this period. In other cases the memory
is apparently unimpaired, and often events and conduct dur¬
ing the drink period are sharply impressed on the mind. The
fact is new to literature that in these toxic states the thought
and conduct of the inebriate is a blank, while the acts, con¬
duct, and associations with others are clearly remembered.
Thus, in a certain case, after a period of drinking, amnesia
of all subjective phenomena will occur, but the subjective life
and surroundings continue clear and distinct.

Later, when this passes off, the mind will be strained to
explain and account for this anomaly. The impression pre¬
vails that an apparent full consciousness of all the subjective
phenomena is associated with an equal subjective realization
of all thoughts and conduct. That a memory of what others
said and did to him is accompanied with a memory of his own
conduct and thoughts. But often the opposite is true. The
one may be clear and the other obscure or a total blank. An
inebriate may describe with reasonable accuracy where he

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395

went, who he met, and what happened during the drink craze,
but be utterly unable to remember what he thought or said, or
what reasons or motives he had at this time. He may remem¬
ber clearly meeting certain persons, going to certain places,
and certain conversation addressed to him, but his conversation
and conduct are not remembered. An illustrative case was
that of a hotel-keeper and periodical drinker. His periods
lasted two weeks, and, after the second day, all recollection
of his conduct and thoughts vanished. Yet, he remembered
being invited to go here and there by certain friends, and re¬
called the advice of his wife and physician, certain business
contracts and counsel, and appeals to do this or that, and to
loan money, or help others, were distinctly recalled; but he
could not say whether he carried out the suggestions or ad¬
vice, or acted on the appeals of others. He remembered going
about to barrooms with others, but could not tell whether he
drank or what he said. He finally disputed a contract made
during this period. He admitted that he remembered the con¬
versation of others and going to consult an architect concerning
the property, but he could not recall his reasons or motives,
or conversation at the time, or the act of signing the paper.
It was found by a study of this case that, on other occasions
similar unusual acts and strange oral and verbal contracts had
been made. Had his memory been as clear of subjective
events and promises as it was of objective events he would
have manifested anxiety to correct the errors he made when
sober. The difficulty of determining these most complex
amnesias is not so great as it appears to be. A man remem¬
bers distinctly the conduct of others towards him, and dwells
on it, but nis own acts may have been criminal, and, if mem¬
ory were equally clear on this, he would seek to cover up or
repair the injury at once. On the contrary, he is oblivious,
showing partial and subjective amnesia. A study of the case
brings out this fact, and places the diagnosis beyond question.

The practical significance of this amnesia is to call attention
to the statements of inebriates and the wide sources of error

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Editorial .

complicated with them. This new phase of memory palsy
will explain many statements now attributed to vice and de¬
ceit. Also the anomalous conduct and statements of reformed
inebriates.

PSYCHICAL PERIODICAL INEBRIATES.

I use this term to describe a class of persons who only drink
to excess on special occasions, and in particular surroundings.
At other times they are strict abstainers, and often very bitter
opponents of spirit taking. One of these classes drink on
holidays, such as Christmas, New Year’s, Fourth of July, and
other national holidays. Another class drink only on occa¬
sions of great excitement, of sorrow, of joy, such as weddings,
political meetings, court trials, accidents, triumphs in business.
A third class drink in the country, and away from all observa¬
tion, or in certain cities, and at certain hotels or houses. A
fourth class drink at the seashore or in the high mountains,
or at the change of seasons, as the beginning of winter or sum¬
mer.

Another class are solitary, midnight drinkers, who never
use spirits except in the most favorable conditions, and in
seclusion at midnight. Others never use spirits except in the
company of certain persons, who seem to provoke an intolerable
desire to become intoxicated. Others are always intoxicated
when out on fishing and hunting excursions. A certain class
never drink only at class or other reunions, or at certain club
dinners, and thus the list might be extended, and would include
many very strange conditions which appear as special exciting
causes. These cases never use spirits except in these particular
environments, which seem to break up all judgment and con¬
trol for the time. Often the holiday drinkers escape by iso¬
lating themselves from all sources of excitement on these oc¬
casions. Going to the country, seeking quiet, with total
change of surroundings and living, and by this means the

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397

drink symptom is controlled. As soon as the holiday is passed
all desire for spirits disappears. The states of excitement are
obscure which rouse this drink craze, and pass away as quickly
as they began. This excitement may continue, but the drink
paroxysm dies out. One man drinks to stupor at the beginning
of a political campaign, then abstains, although exposed to the
same or greater excitement for weeks after. Another becomes
intoxicated with some great successes of life, then never drinks
again, unless the conditions are radically changed. Certain
surroundings of large cities, and particular hotels and houses,
rouse the drink paroxysm. One cannot visit New York, or
another go to Washington, Philadelphia, or Chicago without
becoming intoxicated, and this continues a certain fixed time,
then ceases, or lasts until the surroundings are changed.
Such persons never use spirits elsewhere, and these obscure
psychical states seem to destroy all self-control at the particular
place and time. The mountain and seashore inebriates, who
never use spirits at any other place, display the same impulsive
craving for intoxication. Such cases complain of headache,
nervous trembling, and depression, with extremes of appetite,
insomnia, and drowsiness, as preliminary to the drink craze.
Change of surroundings brings sobriety and relief. The soli¬
tary, midnight inebriates, who never drink unless the con¬
ditions are most favorable for seclusion. Such cases will resist
all temptations to use spirits in company; then go away to some
secluded place and drink at midnight to stupor. If they make
a mistake and the seclusion is broken up, or their presence be¬
comes known, they become sober at once. The influence of
certain fixed and particular surroundings dominates the cen¬
tral organism in a strangely mysterious way. These, and
other drinkers who are never seen to use spirits, except in
special conditions and surroundings, are neurotics with pecul¬
iar susceptibilities to unknown psychical influences. Some
of these cases develop into well marked inebriates, with all
the common symptoms; others remain a lifetime subject to
these nerve storms. Many of these persons early recognize these

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Editorial .

particular exciting causes and avoid them. Others never
realize their meaning, and give way to the impulse to drink
on the occurrence of the special exciting causes. The impres¬
sion prevails that all the exciting causes are under the control
of the will, and that it is always vice in the moral sense which
dominates. A study of these cases indicates some very subtle
causes, both in the surroundings and brain centers. Some
obscure degeneration provokes these psychical nerve strains,
from unknown special conditions and surroundings. A per¬
son who drank only on the Fourth of July was deceived as to
the exact day, being in the country away from noise and ex¬
citement; he was strangely nervous and excited all that day,
but fully recovered after a night’s sleep. This indicated that
something more than the memory of the past, and the domi-
nenee of the idea of drinking that day prevailed.

There are, undoubtedly, many physical and psychical
causes which combine in provoking the drink impulse at cer¬
tain times. These cases occur among the most active workers
in the higher circles of human activity, and it is somewhat
singular that they have not attracted attention or been studied
in any systematic way.

INEBRIETY IN THE ADIRONDACK'S.

The recent popularity of the great northern wilderness of
New York as a residence for consumptives has also attracted
a number of inebriates who hope, by isolation and outdoor
life, to outgrow the drink impulse. * The latter expectation is
unrealized. Literally, this region is occupied by a large
number of persons who use spirits to prevent and check con¬
sumption, and is 'really a dangerous resort for inebriates.

The medical advice given frequently to persons who are
suffering with premonitory phthisis “ to go back to the moun¬
tain regions, live out in the open air, and drink freely of
spirits,” is followed by many persons every year.

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399

The cessation of the acute symptoms encourage the hope
of cure, hence, spirits are used more freely. After a time,
if hemorrhage does not follow, with alarming prostration, a
degree of insomnia and mental feebleness comes on which
sends them home in most cases to die. They always blame
the climate and conditions of surroundings for their failure
to receive benefit. In one instance, recently, at one small
hotel there were eight consumptives who were partially in¬
toxicated most of the time, acting probably on advice to use all
the spirits they could. They were not under the care of any
physicians, but had been sent off alone to treat themselves.
Five of these cases used cod liver oil with the spirits. In a
large hotel, and at one of the most romantic resorts, the bar
trade was not only enormous, but each invalid came provided
with a private supply of spirits. Very little intoxication was
noticed, but a larger number of persons were in a semi-stupid
state, or mildly hilarious much of the time. The drinking
men who hope to keep away from spirits by going to this
region, are astonished to find spirits used so freely by travelers
and invalids, as so-called medicines, and also to find that they
can drink more spirits with less acute intoxication. These
men soon excuse their drinking as medicinal and preventive
for consumption, and by being in the open air most of the
time, can avert the apparent toxic effects more readily than
in lower altitudes.

Many of these persons return and become inebriates, and
die suddenly from pneumonia or some acute disease.

Those who use spirits freely in these regions from medical
advice or other reasons are usually incurables, and die soon,
either of acute tuberculosis, nephritis, or pneumonia, follow¬
ing inebriety. When spirits are continued low forms of
dementia appear, with often fatal termination. The general
degeneration, which, centered in the lungs, is concealed by the
alcohol, and intensified into other and more diffused conditions
of dissolution. The use of alcohol in consumption as a pre¬
ventive is dangerous. In a large proportion of cases it is fol-

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Editorial .

lowed by degenerations more serious and fatal than the origi¬
nal disease.

The intimate relation and rapid alternation from inebriety
to consumption, and consumption to inebriety, is a well-ob¬
served clinical fact. Both belong to the same family group
of neuroses, and the reckless advice to use all the spirits pos¬
sible to prevent the one, while it may not always be followed
by the other, will certainly intensify and provoke degenera¬
tions that are never removed.

Inebriety in high altitudes is more intense and rapid in
its progress. General progressive anaemia and exhaustion
follows. In some instances this is marked by intense cerebral
irritation and delirium, in others by acute inflammatory affec¬
tions. To send inebriates into high altitudes is not safe unless
the conditions and surroundings are most favorable, and the
history of the case promises relief by this change.

PARETIC STATES IN INEBRIETY.

The paralyses noted in inebriety are obscure and often com¬
plex forms of what is termed general paralysis. They are
practically progressive cerebral degenerations and are marked
by organic changes in the encephalon and its coverings, or in
the spinal cord and membranes, and sometimes in the sym¬
pathetic ganglia. It may include many forms of cerebral
degeneration, which occur independently, and go on in steady
progression or with halts and long intermissions. Pathologic¬
ally it is often found to be a chronic meningitis or sclerosis
of the connective tissue of the brain or degenerative lesions
of the great sympathetic, a myolitis, a diffuse, chronic, inter¬
stitial, menigo-, mvelo-, encephalitis, and, lastly, an affection
beginning in the brain cortex or in the cord, or in the neurine
organs of special sense, or in the peripheral nerves.

From this it will be evident that general dementia is an
essential symptom of the disease.

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401

Paralysis following alcoholic excess, while having all the
marked symptoms of these cases, will vary in progress and
duration. Often it is associated with epileptiform attacks,
and appears to have reached extreme stages at once, then
changes materially under appropriate treatment. One of the
distinguishing symptoms, according to Regis, is the paretic
character of the pupils, in some cases absolutely immobile, es¬
pecially the one that is most dilated. Besides this the pupil-
iary aperture is very often misshapen, oval, notched on its
borders, the coloration of the pupil loses its sparkle and trans¬
parency, usually dull and cloudy, the visual acuteness is
ordinarily diminished. The mental state is usually confused
and stupid, the inequality of the pupils remain. The exalt¬
ation is temporary and changeable, with hallucinations and
paroxysmal delusions. The affections of speech and ataxy of
movements, associated with tremors and trembling of the
muscles of the face and legs, vary widely.

Many cases have associated syphilis, sunstroke, and ma¬
laria, and it is difficult to determine which of these causes are
prominent, and whether the degeneration from alcohol is an
exciting cause alone. The typical forms of paralyses may
follow an excess of spirits, and pass away, when a degree of
restoration follows, or appear in the case where alcohol is
used constantly in so-called moderation.

All cases of inebriety in which expansive deliriums, and
general exaltations of the feelings are present, may be called
paralysis. Associated with this are present many mixed de¬
grees of defective muscular and motor activities, and inco¬
ordinations of words and defective articulation.

Many varied physical and psychical symptoms appear and
disappear, or continue in different degrees of intensity. If
the origin is alcoholic great changes of symptoms will follow
appropriate treatment. If of syphilitic, saturnine, malarious,
or from lesions of fever or sunstroke, much can be expected
from treatment. Final recovery is not to be expected, halts

Vol. XVIIl-62

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402

Editorial .

and changes of the symptoms will occur, but the degenera¬
tion which has become so manifest will leave a permanent
impress on the brain. It is difficult to differentiate a form of
paralysis that is due to alcohol alone, but a careful study of the
clinical history of persons who use spirits will reveal many
symptoms that are common to paralysis. The terms paretic
dementia, progressive palsy, with peculiar delirium, and psychi¬
cal symptoms of degeneration, describe many cases of inebriety.
Evidently, further study will clear up the present confusion
of terms and symptoms that are so interwoven as to be difficult
to separate and understand.

ANNIVERSARY MEETING OF OUR ASSOCIATION.

A memorial meeting will be held at the New York Aca¬
demy of Medicine, New York city, Friday evening, Novem¬
ber 20, 1896 , to celebrate the twentieth anniversary of tjhe
publication of the Journal of Inebriety , and the twenty-sixth
year of the Association for the Study and Cure of Inebriety.

A generation has passed since this Association and Journal
began their work. Inebriety has become a province of
science, and is studied from a higher and wider point of view.
Its literature has come into full recognition, as outline trac¬
ings of a new field of pathological psychology. The closing
years of the century bring into view an increasing number of
problems, the solution of which must come along these lines
of research. Most of the pioneers and early workers in this
field have passed away. It is proposed to devote our annual
meeting exclusively to a historic review of the circumstances
and conditions which led to the formation of the Association
and the Journal , and the founders and their efforts to open
this new realm of science.

The following program of addresses and papers will be pre¬
sented on this occasion:

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Editorial .

403

The First Meeting of the Association and the Original
Members, by Dr. L. D. Mason, Brooklyn, N. Y.

The Journal of Inebriety , its Inception and Birth, and the
Early and Later Literature of the Subject, by T. D. Crothers,
M.D., Hartford, Conn.

The First Asylum for Inebriates and its Founder, Dr. J. E.
Turner, by Dr. C. H. Shepard, Brooklyn, N. Y.

The First State Asylum for Indigent Inebriates and its
Work, by Dr. M. E. Hutchinson, Foxboro, Mass.

The First Asylum for Opium Inebriates, its Growth, Litera¬
ture, and Progress, by J. B. Mattison, M.D., Brooklyn, N. Y.

The First Home for Inebriates and its Work, by Dr. V. A.
Ellsworth, Boston, Mass.

Empiric and Charlatan Efforts to Cure Inebriates, by N.
Roe Bradner, M.D., Philadelphia, Pa.

The Abuse of Alcohol in Medicine and its Historic In¬
fluence, by Dr. I. N. Quimby, Jersey City, N. J.

The Origin and Growth of Asylums for Inebriates in Great
Britain, by Dr. Norman Kerr, London, England.

H. W. Glasenap’s investigations show that cocaine can
be detected either as such or as ecgonine after thirty-three
days’ exposure to the influence of putrefying flesh or human
blood. In cases of poisoning, however, if death has ensued
within two hours, it will be found unaltered, but if more than
four hours have elapsed before death, it will be found (in the
urine) as ecgonine.— Journal of the London Chemical So¬
ciety.

Mathews Medical Quarterly is to be changed to Mathews
Quarterly Journal of Rectal and Intestinal Diseases. This is
to describe exactly the contents and purpose of the journal.
This is the only journal in the English language in this field,
and is a very valuable and useful publication.

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404

Clinical Notes and Comments.

Cliqidhl ]sfote$ <m<l Conqmer\t^.

THE USE OE WHAT DRUGS AND MEDICINES WILL
RENDER AN APPLICANT UNINSURABLE,

AND WHY ?

George R. Chitwood, Jr., M. D., Indianapolis, Ind.

Many of the medicines given in health will, if long con¬
tinued, produce a diseased condition of the animal organism,
either affecting a part or the whole of the system.

The effect, or effects, of almost any single article known
as a medicine proper, that is, a remedy used by the physician
in disease, whether as a palliative or otherwise, will, if car¬
ried to the extent of forming a habit, so derange the system
as to make the individual uninsurable.

Medicines are equally as deleterious as the alcoholic
beverages, and are just as likely to form a habit; and the
effects left by them are equally as damaging to the physical
and mental health.

To undertake to give a list of such medicines is no small
task, as in my opinion such a list would include a large pro¬
portion of our therapeutical and chemical agents. However,
I will include the bulk of the narcotics, some of the tar pro¬
ducts, quinine, opium, morphine, cocaine, belladonna, Indian
hemp, digitalis, arterial and nervous sedatives; the active
cathartics, diuretics, mineral and vegetable acids, alkalies,
antispasmodics, and others.

Many physicians are aware of the bad effects of opium
in any of its forms, quinine, cocaine, certain of the cathartics,

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Clinical Notes and Comments .

405

as aloes, gamboge, podophillin, calomel; how by their over and
unnecessary action they may and do leave the mucous mem¬
branes of the intestinal tract in an irritated and diseased con¬
dition, which condition is frequently the cause of so many
of our chronic diseases affecting this portion of the system.

Among a few of the diseases resulting from “ over-phys¬
icking ” may be mentioned chronic constipation, hemor¬
rhoids, chronic diarrhoea, prolapse of rectum, occasional in¬
tussusception of bowels, and, in a few instances, paralysis of
the intestines, particularly the rectum.

And so may a long and continuous use of certain of the
diuretics leave their bad or diseased effects, such as a want of
power to control the act of urination, paralysis of the neck of
the bladder, congestion, and other diseases of the kidneys, and,
occasionally, desquamative inflammation of the kidneys
(Bright’s disease). From a long and continuous use of opium,
morphine, cocaine, and a few, if not all, of the tar products,
we have, as a result, a slow poisoning of the brain, blood,
nerves, and a badly deranged condition of the secretory sys¬
tem, with progressive and frequently rapid loss of flesh, bring¬
ing the users of these remedies down to living skeletons, with
imbecile and childish intellects, and digestive organs as feeble
as babes. Besides, sleep is interrupted to such an extent as
to make a good night’s rest a thing of the hazy past—a stranger
to these strange and mysteriously-acting persons.

While alcoholics leave their diseased effects upon the brain
and the digestive organs, their long-continued use quite often
produces delirium tremens, and those with sympathetic im¬
aginations, brooding over the horde of snakes, imps, and
devils that crowd so thickly around their fancy, are driven to
self-destruction, thinking thereby to escape these imaginary
foes.

Quinine is well known to affect the brain, the mind, the
hearing, the digestive organs, the blood (congesting it), and
otherwise deranging the system.

The use of most medicines, if continued for a definite

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406

Clinical Notes and Comments .

period, may fix a habit on the users; and while many of these
habits might easily be cured, most of them continue, simply
because the use of the remedy gives an ease, which, with all
medicine users, is sufficient excuse for continuing it. On this
account we are inclined to believe that all who have medicine¬
taking habits are poor risks for life insurance, and . should be
rejected, as many of this class possess weakened, if not
diseased bodies, which make them very liable to contract
disease. All of these sickly beings have their lives shortened,
and this alone should be a prime excuse for refusing an in¬
surance policy, if insurance companies are seeking for long-
lived applicants. We hold that these medicine-gorging peo¬
ple are not suitable risks for any kind of insurance, regular
life or accident. They belong very properly to the grave¬
yard class, for they are going to the cemeteries fast enough
to be called “ scorchers.”

It would be almost as safe for life insurance companies to
take risks on those afflicted with the first stage of consumption,
as on some of our medicine fiends, as they are no more likely
to cease their habit than the consumptive is to recover.

Habit, when once formed, requires a will force that but
few possess to break. While those with a medicine habit
may keep it a secret, they go on, realizing the slow, sapping,
and killing effects, but too feeble, mentally and otherwise, to
conquer it. Many of this class seek insurance, feeling that
their lives are being shortened by their habit, and grow daily
more anxious to keep the wolf from their poor wives and
helpless little ones. Their habits make their lives dreams,
and so agreeable to them that they do not care to ever again
wake to their former selves, and so they go on, taking their
“ good medicine,” building air castles that carry their fancy
to the skies, almost to St. Peter’s heavenly gate, hoping, if
such beings ever hope, that when this earthly strife is ended,
they will forever be freed from their debasing habit.

The medical examiner for a life insurance company should
be an expert as regards his work with an applicant for insur-

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Clinical Notes and Comments .

407

ance*. This quality is necessary for the good of all concerned
in such lines of business. He should carefully study, wher¬
ever the opportunity presents, all of the applicant’s habits.
Of course, we admit this cannot always be done, as most ex¬
aminations are hurriedly made.

But in a few instances, at least, the examiner might make
a plea of more time, then shadow, as it were, the applicant,
and endeavor to learn whether he has a habit injurious to his
health or not. This suggestion is only made whenever the
examiner entertains a doubt in regard to applicant’s ability to
pass a successful ordeal.

The medical examiner should never hesitate to question
the applicant closely, just the same as the practising physician
does his patient.

It is well known that those who seek insurance conceal
everything from the examiner that might act against their
chances for insurance, and hence it behooves the examiner
to be ever on his guard. This class of applicants will say
and do everything in their power to give themselves a “ healthy
standard,” and the truly good and honest examiner must be
on his guard, keeping his eyes and ears open for any mis¬
leading statement.

Finally, it is our humble opinion that any one addicted to
a medicine habit, particularly if of long standing, and with
any visible physical or other signs that the general health
is being infringed upon, is unfit for life insurance, as this class
is very risky, being liable to end their existence at any mo¬
ment—voluntarily or otherwise.

Those free from the habit of drink, or medicine dieting,
are risky enough, for many of this class will deceive, or at¬
tempt to deceive, the medical examiner as regards hereditary
tendencies to disease and other transmitted conditions that
are known to shorten life.

We believe it is safe to reject all who possess habits that
are known to produce functional or organic diseases, and as
most bad habits tend to derange health, life is shortened, there-

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408

Clinical Notes and Comments.

by greatly tending to embarrass, if not bankrupt, many life
insurance companies. Reject all such, unless life insurance
companies are established on the purely philanthropic and
charitable order, with an unlimited capital reserve; then un¬
limited policies are in order.

VINO-KOLAFRA.

The note on this preparation of kola nuts, published in the
last number of the Journal, has brought a number of inquiries
to this office for further particulars. We reply that our ex¬
perience is simply limited to cases where alcohol is withdrawn,
and during the period of the gradual reduction of opium. In
the former it seems to be particularly valuable. The follow¬
ing case is a fair illustration: An inebriate of long duration,
much debilitated, and filled with morbid fears of dying if
spirits were removed, was given two ounce doses of Vino-Kola-
fra every three hours. The spirits were removed at once, all
fears disappeared and he became calm. Recovery followed,
the Vino-Kolafra was stopped at the end of a week, and all
desire for spirits disappeared. There seemed to be in the wine
a sedative action, and in the kola a stimulating power, which
overcame the depression from spirits, giving new force for
building up and restoration.

The value as a substitute for spirits is beyond question,
and undoubtedly it has some peculiar power to neutralize and
overcome the cell and nerve irritation which demands nar¬
cotics for rest.

In two cases of opium addiction, the same stimulating
tonic power was noticed. The intense depression seemed to
pass away, from smaller doses, when oftener repeated. To
our many correspondents we urge that this drug be tried in
the first stage of treatment of alcohol and opium inebriety,
using no other drugs at the time, then carefully noting its
effects. As to its further use, experience must determine its
value.

It can in all probability be relied upon as anti-alcoholic, and
a remedy which destroys the desire for spirits at the time.

The Brunswick Pharmacal Co., of Hew York city prepare
this drug, and they have already accumulated quite a litera¬
ture, which is worthy of much consideration.

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Clinical Notes and Comments.

409

A very valuable report has recently been drawn up by a
French specialist on the spread of alcoholism and its effects.
In the various institutions of the Department of the Seine, in
France, 775 persons suffering from alcoholism were received
in 1894—624 men and 151 women. The form of alcoholism
in the case of the males comprised 282 cases of alcoholic deli¬
rium, 332 cases of chronic alcoholism, and 10 cases of absinth-
ism—a form of disease which appears to be almost exclusively
confined to France and Algeria. Among the women there
were 90 cases of alcoholic delirium, 60 of chronic alcoholism,
and 1 of absinthism. In reviewing these cases, Dr. Magnan
says: “ As a consequence of alcoholism, we find an increase

of general paralysis, and, what is still more serious, an aug¬
mentation in the number of idiots, of youthful epileptics,
whose family history reveals almost always the alcoholism of
the father, and sometimes of the mother, and frequently of
both.” It becomes, therefore, a social duty, and a necessity
in the interests of public health, to endeavor by all the means
in our power., to stay the ravages of this scourge, which is
worse in its effects, because these effects are more far-reach¬
ing than the most devastating epidemics.— Charlotte Medical
Journal .

We have called attention to Somatose , a meat nutrient
prepared by W. H. Schieffelin & Co., N - . Y., and believe that
this far exceeds any beef preparations, in various disorders of
the stomach and general anaemia. It is put up in the form of
crackers, and is both palatable and strengthening as a food.

Protonuclein is a new remedy for all asthenic conditions,
and is practically a tissue builder. It increases the white
blood corpucles, and is antoxic in'its power.

Peptenzyme is a digestant of great power, and groups
the ferments necessary to carry full digestion.

These new drugs are put on the market by the famous
manufacturing firm of Reed & Carnrick , which in itself is a
guarantee of their value and power.

Vol. XVIII— 63

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410

Clinical Notes and Comments .

Parke , Davis & Co. have made a most valuable addition to
the list of remedies for dyspepsia in Taka-Diastase. This is
practically a specific for faulty digestion of starch, where pep¬
sin is of no value. These disorders are now most successfully
treated, by special remedies for each condition. Taka-Dias¬
tase is the great remedy for this special condition, of failure
to digest starch.

Antikamnia has become a popular drug in England. As
an analgesic, antipyretic and anodyne drug, it has come into
general use in this country. For certain neuralgias and head¬
aches following inebriety, it has almost a specific effect. It
has become one of the drugs which cannot be dispensed with
in general practice.

W. Irving Hy^lop, M.D., 4408 Chestnut St., West Phil¬
adelphia, Pa., says; “ I have used Celerina quite largely
both in private and hospital practice, and with gratifying re¬
sults. It is void of repugnant taste, and is readily retained by
the stomach. My experience with Celerina has been con¬
fined chiefly to its use in nervous diseases, particularly loss
of nerve power, and the opium habit, in which conditions
it has served me well, and I shall continue to prescribe it both
in private and hospital practice.

In the treatment of atonic dyspepsia, as in that of other
stomach disorders, regulation of diet is the first step
to be considered. Next is the selection of food
which consists of nutritious and easily-digested articles.
When the powers of digestion are weakened, special aids
to this function are plainly indicated, and for this, Maltopep-
sine (Tilden’s) in combination with strychnia and the bit¬
ters, is the most potent of remedial agents.

One of the great table waters of this country is the Are-
thusa Spring Water of Seymour, Conn. Send for circulars.

We call attention to Bovinine , a new and well-known form
of condensed food which has attained great prominence as a

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Clinical Notes and Comments .

411

stimulant. Its use as a restorative is very general in many
hospitals, and will undoubtedly come into very general use.

We have never ceased to call attention to Horsford’s Acid
Phosphate . It has proved to be almost a specific in many
cases of inebriety.

The celebrated firm, C. F. Boehringer & Soehne of Ger¬
many have introduced a new analgesic and sedative remedy
called Lfictophcnin , which promises to be very practical
and useful as a harmless hypnotic. This firm, through their
New York house, are presenting many new remedies, and
fine preparations of old ones, that attract much attention.
One of these drugs is Ferratin, which feeds the blood, an¬
other, Papain, a vegetable digestive.

Wheeler’s Tissue Phosphates is a nerve food, as well as
nutritive tonic of superior value. It has been before the pro¬
fession for twenty years, and its value is fully recognized
wherever it is used.

The Worcester Fire Pail Co is an excellent extinguisher
having the merit of simplicity, effectiveness, always ready for
use, and always practical and to be depended upon.

Listerene is the standard antiseptic, of uniform, and of ac¬
curately determined qualities. It is becoming more and more
widely used every year, and is numbered among the house¬
hold remedies essential for common emergencies.

Dr. Macloud of Glasgow, in discussing the use of seda¬
tives in insanity, said: “ The most efficient hypnotic I have
found in these and allied cases is a combination known as
Bromida. We have found this formula to meet more
conditions than any other. Its value is beyond all question.

Arsenauro has proved to be of exceptional value in sev¬
eral cases of inebriety, in which general anaemia existed, with
a history of syphilis. After the removal of alcohol, this drug
was exclusively used. In two instances a profound disgust
for all spirits appeared. In one case an old eczema of long

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412

Clinical Notes and Comments .

duration disappeared,, and in three cases headaches and symp¬
toms of great weakness passed off. In all, a profound change
of nutrition and improvement of all the organic processes
followed. In three cases the origin of the drink craze was
in all probability the reflex irritation from the poison of syphi¬
lis, and Arsenauro acted like a specific. The acute symptoms
disappeared very quickly after the drug was used. In one
case malaria appeared to be an early exciting cause, and this
drug acted equally as prompt.

It would seem from this experience that Arsenauro is
a powerful tonic, and anti-syphilitic remedy, acting directly on
the trophic nerves, and general nutrition. Also neutraliz¬
ing and antagonizing the poison of syphilis and the degen¬
erations which follow from it. This would be a confirmation
of the common experience of all practitioners who use arse¬
nic.

Inebriety is always a profound constitutional disorder,
that can only be successfully treated by great alternatives like
arsenic, mercury, and allied remedies. There can be no
question that Arsenauro is a most valuable drug in inebri¬
ety, and may be used in all cases with great confidence. We
shall be pleased to report a larger experience with it in the
future. The Charles Roome Parmlee Co., who prepare Ar¬
senauro, also have Mercauro, a similar preparation of mer¬
cury, arsenic, and bromide.

Maltine and Coca Wine has proved of great value in
many cases, where profound exhaustion and anaemia are pres¬
ent, and great dread of removing spirits. This has proved an
excellent medicinal substitute.

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Full text of "Quarterly Journal of Inebriety 18.1896"

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