pressed in terms of boric acid, for a limited period of time with slight danger
of injuring the health. The chief objection to the employment of these sub-
stances as food preservatives seems to rest upon the fraud in permitting inferior
goods to be marketed as high class products. This applies especially to
meats and milk although the addition of small quantities of these substances
may be beneficial since it delays the souring of the latter. If larger amounts
are used with fraudulent intent, the milk is apt to be kept too long, to be
of poor quality and the quantity of the preservative may be sufi&cient to
injure infants who take the milk as a routine.
Treatment consists in stopping the ingestion of the adulterated food stuffs
and the employment of means calculated to relieve the existing symptoms.
ALCOHOLISM.
Acute Alcoholism.
Definition. The result of the imbibition of a considerable amount of
alcohol in any of its forms and within a short space of time. The quantity
necessary to produce drunkenness varies greatly with the individual.
298 THE IXTOXICATIOXS.
Sjrmptoms. These are chiefly referable to the nervous system, and while
the sequence of their appearance is not constant there is usually a primar}^
stage of excitation during which the subject's face becomes flushed, his eyes
brightened and his tongue garrulous; the speech is at first coherent but soon
becomes senseless; muscular co-ordination is disturbed as e\-idenced by the
staggering gait. Locomotion soon becomes impossible and finally alcoholic
coma super\'enes. Other individuals are differently affected; instead of the
priman' excitement being evidenced by jollit}' and good nature it may be
characterized by moroseness and the subject may be incited to violence and
even murder by very slight provocation. The stage of narcosis, however,.
ultimately ensues as in the pre\nously described t\^e of alcoholism, if suffi-
cient liquor is taken.
Alcoholic coma is not always easy of diagnosis. The face is usually flushed
but may present a cyanotic appearance, the pulse is strong and fuU, respira-
tion is deep, slow and sometimes stertorous. The temperature may be
subnormal, at times even below 90° F. (32.2° C). The urine and faeces
may be passed involuntarily the pupils are dilated and muscular twitchings
may be present. The individual may be temporarily aroused in most instances
by pressing upon the upper margin of the orbits at the junction of their inner
and middle thirds — the points of emergence of the supra-orbital ner^^es.
There is usually an odor of alcohol upon the breath. One of the most common
of the mistakes to which the young ambulance surgeon is liable is the con-
founding of basilar fractures of the skull for alcoholism. This mistake is
rendered a particiilarly easy one by the frequence with which the two condi-
tions co-exist. In fracture the coma is usually deeper, the respiration stertor-
ous and the pupils are often unequal. Bleeding from mouth, nose or ears is
very characteristic. The difficulty of differentiation is often so great that it is
always the part of wisdom to give the patient the benefit of ever}' doubt and
to consider aU dubious instances of coma as proper for admission to a
hospital.
Cerebral apoplexy may be separated from alcoholic coma by its deeper
unconsciousness, pupiUar}' inequality, the evidences of cardiac or vascular
disease or of partial paralysis.
In urcRmic coma the taint of alcohol upon the breath is lacking, the pulse
is likely to be of high tension and the patient may exhale a urinous odor.
The pupils are variable; the urine when dra-^m by catheter shows the pres-
ence of albumin and casts.
A consideration of acute alcoholism is not complete without mention of
the ver}^ serious effects of indiilgence in diluted methyl alcohol {wood alcohol).
This liquid is often drunk by confirmed alcoholics when it is impossible to
procure ordinary liquors. The effects of this form of alcohol are more pro-
longed than those of ethyl alcohol, lasting from 2 to 4 days, while those of the
CHRONIC ALCOHOLISM. 299
latter seldom persist for more than one-quarter of this time. The most per-
manent effect is upon the optic nerves, blindness, which may last for a long
time, and optic neiiritis are common sequences of the ingestion of this sub-
stance.
Treatment. Recovery from the acute effects of alcohol is usual even if no
treatment is administered; the event may, however, be hastened by thoroughly
washing out the stomach, or, if the patient is able to swallow, by giving an
emetic consisting of 20 grains (1.33) each of powdered ipecac and zinc sulphate,
or of warm mustard water — 2 drachms (8.0) to 8 ounces (250.0). The hj'po-
dermatic administration of tj to to of a grain (0.0044 to 0.006) of apomor-
phine hydrochloride is an efficient method of relieving the stomach of its
contents and at the same time bringing about a diminution of violent nervous
symptoms if these are present. These latter may be usually controlled by
the administration of hydrated chloral in dose of 10 to 20 grains (0.66 to 1.33)
with I or 2 drachms (4.0 to 8.0) of sodium bromide. If stimulation is nec-
essary the patient may receive a drachm (4.0) of aromatic spirit of ammonia
and if there is any tendency to collapse, frictions and hot applications should
be employed. "W^en convulsions are present, which is rarely the case, a
little chloroform should be given by inhalation until the sedatives given by
mouth have had time to exert their effect.
Chronic Alcoholism.
Definition. A condition resulting from the habitual and intemperate
use of alcoholic beverages. What constitutes the "intemperate use" of
alcohol cannot be definitely stated, for certain individuals are able to take
without apparent harm quantities of this substance which would exert, in
more susceptible subjects, most marked untoward effects.
Dipsomania is a form of chronic alcoholism, the tendency to which is
hereditary, which is characterized by a periodic desire for alcoholic excess
and is evidenced by debauches at varying intervals, the subject being wholly
free from the craving during the intervening periods.
Effects of Chronic Alcoholic Poisoning. Among the common results of
chronic alcoholism are chronic gastritis, gastric dilatation, especially in beer
drinkers, hepatic cirrhosis, delirium tremens and mania. Many other diseases
have been attributed to the effects of the chronic use of alcohol among which
may be cited gout, peripheral neuritis, pachymeningitis, organic heart disease
and chronic nephritis; in fact, but few organs and tissues are not changed in
some way in chronic alcoholism and its results. Of the changes met
in this condition two groups are described, namely sclerosis and steatosis,
WTiile these anatomical alterations are in process of development the exterior
of the body assumes characteristic appearances. The individual may be
300 THE INTOXICATIONS.
either pale and flabby, but fat, with a heavy and imbecile expression or he
may have a dusky red or purplish, pimply and bloated skin, with swelling
under the eyes, yellow and injected conjunctivae, and blue and thickened
lips.
Alcoholics are especially likely to contract pneumonia, tuberculosis and
other infectious diseases, and when attacked by them show less resisting
power than do previously healthy persons. They are also bad subjects for
surgical operations and bear anaesthesia poorly.
The^post mortem changes in the organs and tissues of alcoholic individuals
show no characteristic changes, there is often found, however, in patients
dead from mania a potu an oedematous condition of the brain and its mem-
branes, the so-called wei brain.
Symptoms. These are referable to the various organs and systems whose
functions have been impaired and whose structure has been altered by the
effect of the alcohol.
The Digestive System. Chronic catarrhal gastritis is an almost constant
affection in the chronic alcoholic. It is evidenced by anorexia, foul tongue
and breath, constipation, nausea and vomiting, especially before eating in
the morning, the so called "water brash." Often these symptoms are relieved
by the day's first potation.
The liver is subject to definite changes partly as a result of chronic over-
indulgence in alcohol and from accessory products used in manufacture
or from additional substances introduced in "blending." From these
arise symptoms in accordance with the existing conditions of cirrhosis, fatty
degeneration, etc. These changes by no means always occur but are fre-
quent and as a result of the compression of the portal circulation, due to the
cirrhosis and consequent contraction of the new interstitial tissue, various
manifestations appear such as those due to congestion of the gastric mucous
membrane, hemorrhages from the alimentary tract, haemorrhoids, splenic
enlargement, etc. The characteristic facies of the alcoholic with its dilated
veins, reddened nose — which is often the acne rosacea of the dermatologists —
the swellings beneath the eyes and the icteric conjunctivae, usually accom-
panies the disorders of the digestive tract and liver.
From the changes in the circulatory system the symptoms due to cardiac,
renal and arterial disease result. Of these vertigo, apoplectic seizures and
the various other manifestations of arterial degeneration are most important.
The Nervous System. Such symptoms as tremors of the hands and tongue
and unsteadiness in the control of muscular acts are very common; the mental-
ity is sluggish, the patient is irritable, restless and deteriorates morally; the
memory is impaired and the intellect becomes weakened generally; finally
dementia and insanity may supervene. Multiple peripheral neuritis is fre-
quent and will be considered elsewhere. Epilepsy may also occur as a sequence
CHRONIC ALCOHOLISM. 30I
of chronic alcoholism but is likely to disappear with the resumption of proper
habits. At times there develops with an alcoholic neuritis, and sometimes by
itself, a peculiar condition characterized by hallucinations of sight, labial
tremors, thickness of speech, impairment of memory, disordered ideas of
time and space and imaginative explanations of actual incidents, to which
the term psychosis polyneuritica or Korsakoff's disease has been applied.
Changes in the nervous system are found after death but are not charac-
teristic; of these hsemorrhagic pachymeningitis, thickenings and opacities
of the pial and arachnoid membranes, and even, in advanced instances, en-
cephalomeningitis with meningeal adhesions should be mentioned.
Treatment. Chronic alcohoHsm can hardly be treated satisfactorily at
the patient's home; success is far more readily attained at an institution where
outside influences can be excluded, alcohol cannot be obtained unless con-
sidered advisable by the physician in charge and the patient can be kept
under the strict supervision of attendants. An excellent substitute for insti-
tutional treatment is a prolonged sea voyage or a sojourn in the woods such
as is afforded by a hunting or fishing trip where no alcohol is taken and the
inebriate is associated with one or more congenial companions who are not
drinkers. It is the present uniformly held belief that an entire withdrawal
of the alcohol is better than a gradual "tapering off" unless the abstention
results in an attack of delirium tremens, when it is usually necessary to aUow
the drug in varying amount. The substitution of narcotics such as chloral,
cocaine and the like for alcohol is to be unhesitatingly condemned. Sleepless-
ness and nervousness may be controlled by the administration of the milder
hj-pnotics such as the bromides, sulphonme thane (sulphonal), sulphon-
ethylmethane (trional), veronal and paraldehyde. Morphine should not be
used unless the patient's condition renders it absolutely necessary and other
sedatives have failed. Even then it should not be prescribed as a routine
but occasionally only, for the danger of acquiring the habit is great.
Hyoscine hydrobromide has recently been advocated as an excellent means
of allaying the desire for alcohol and the nervous symptoms which follow its
suspension. It may, if necessary, be given to the physiological limit even
to the production of dr\Tiess of the mouth and delirium. Doses of yw
of a grain (0.0006) may be administered h}'podermatically every 2 or 3 hours
until the nervous manifestations are relieved. These may be kept in a state
of abatement by less frequent doses until the drug finally is entirely stopped.
The much exploited gold cure and other advertised institutional treat-
ments possess no special recommendation.
The addition to the liquor taken by the patient of apomorphine or other
substances and the hypodermatic administration of the former drug after
drinking may produce a distaste for alcohol. It has also been asserted that
hypodermatic doses of y^^-o" of a grain (0.0006) of atropine sulphate given
302 THE INTOXICATIONS.
several times a day will shortly render alcohol distasteful to the patient and
productive of emesis vi^ithout the addition of nauseating drugs.
During treatment the patient's digestion should be kept in as good
condition as possible, the bowels should be regulated by means of mild laxa-
tives or by occasional purgation with fractional doses of calomel followed by
a saline, and stomachic bitters together with such tonics as strychnine and
cinchona are usful. Any tendency to circulatory failure must be combated
by the ordinary means, strychnine, digitalis, etc. Acute syncope or collapse
necessi|0,tes the hypodermatic administration of diffusible cardiac stimu-
lants such as camphor and aether and of the aromatic spirit of ammonia or
the compound spirit of aether by mouth.
The diet should be nourishing, abundant and easily digestible. Tea and
coffee, on account of their stimulant properties may be allowed.
Delirium Tremens.
Synonym. Mania a Potu.
Definition. An effect of the prolonged use of alcohol characterized by
delirium with hallucinations and extreme prostration.
Symptoms. The syndrome delirium tremens is a result of the prolonged
action of alcohol upon the cerebral cells but is often induced by a sudden
withdrawal of the drug. Alcoholic excess in a temperate individual does
not bring on an attack but a debauch may be followed, in the case of a chronic
alcoholic, by typical mania a potu. Alcoholic subjects are very prone to
attacks when prostrated by acute disease, particularly pneumonia. Delirium
tremens is also a frequent consequence in alcoholics of a mental shock or physical
injury such as a fractiured limb or other result of traumatism. Prevention
may be possible, in the latter instances, by allowing these patients alcohol
in moderate quantity.
The onset of an attack is marked by sleeplessness, restlessness and depres-
sion; these symptoms are shortly succeeded by a delirium characterized by
hallucinations of sight and hearing. Talking is continuous and incoherent
and restraint may be necessary, for the patient may desire to leave the house
on imaginary business. The delusions of sight may take the form of animals
rats, mice, snakes, insects, etc., which the patient imagines are pursuing him or
crawling about his bed or over his body. The fear induced is intense and
constant watching is necessary to prevent attempts to escape. The hallu-
cinations of hearing are less usual but conversations with imaginary persons
may be carried on, imaginary voices and noise may be heard. Muscular
tremor is marked and sleep is impossible. There is extreme weakness and
the pulse is soft, frequent, compressible and, perhaps, irregular. The tern-
DELIRIUM TREMENS. 303
perature is elevated to 101° to 103° F. (38.3° to 39.5° C.) unless acute com-
plications are present, when it is higher.
The diagnosis is simple. The patient should be thoroughly examined
when first seen for surgical injuries and daily physical examination of the
lungs is necessary, for congestion at the bases is frequent and may develop
into pneumonia; on the other hand pneumonia, especially that at the pulmonary
apices may be accompanied by a delirium resembling that of mania a potu.
Meningitis, a serous form of which {wet brain) is often present, simulates
in its symptoms delirium tremens, but may be differentiated from the
latter condition by an absence of alcoholic history and the patient's
appearance.
The prognosis varies, but, if there are no complications present, recovery
usually takes place within a week, the hallucinations, sleeplessness and tremors
gradually disappearing. In hospitals, however, the type of alcoholic subject
generally observed is in a weakened and debilitated state and the death rate
is consequently high, the patient gradually falling into the typhoid condition
with feeble and dicrotic pulse, dry and cracked tongue, and low, muttering
delirium; death from cardiac failure supervenes in a great number of instances.
In patients who recover recurrences are common.
Treatment. The patient should be put to bed in a quiet darkened room;
alcohol should be withdrawn unless its administration is necessary to combat
adynamia; even if there is marked cardiac weakness in many instances it is
preferable to stimulate by means of ammonium which is best administered
as the solution of the acetate (liquor ammonii acetatis) in doses of J an ounce
(15.0) repeated every 2 or 3 hours if necessary. The aromatic spirit is also
useful and may be given in doses of | to i drachm (2.0 to 4.0). Strychnine
sulphate, -3V of a grain (0.002) or more if indications are present may be
employed as well.
The reUef of the sleeplessness is most important and may be accomplished
by the administration of the bromides and chloral, J drachm (2.0) of sodium
bromide with 10 to 15 grains (0.66 to i.o) of hydrated chloral often being
sufficient. Chloral, however, should not be employed if there is tendency
to heart weakness. The writer has obtained excellent results in his service
in the alcoholic wards of Bellevue Hospital with paraldehyde in doses of
2 drachms (8.0) frequently repeated if necessary. Sulphonethylmethane
(trional), in doses of 10 to 20 grains (0.66 to 1.33), is also useful and
often acts well when given in combination with 5 grains (0.33) of veronal.
If the delirium is uncontrollable by other means hyoscine hydrobromide —
xio^ of a grain (0.0006) — may be given hypodermatically. Morphine should
be administered with caution if at all; when all other measures fail it may he
given hypodermatically in doses of j of a grain (0.016) but should seldom
be repeated more than twice, the effects being watched with great care. Cold
304 THE INTOXICATIONS.
baths and hot or cold packs, repeated if necessary, are often useful in the
relief of the restlessness.
If there are S3'mptoms indicating meningeal involvement (wet brain),
such as stiffness and rigidity of the neck, etc., the ice helmet should be appHed.
Restraint is often necessary to keep the patient in bed and here the employ-
ment of a folded sheet placed across the body and pinned under the mattress
is to be preferred to straps.
At the beginning of the treatment the bowels should be freely moved and
throughout the course of the affection the channels of elimination should be
kept open by means of frequent draughts of water and laxatives when neces-
sary.
The patient's strength should be maintained by means of frequent feeding
with easily digestible and assimilable foods such as milk, peptonized if pre-
ferred, and nourishing soups. As the symptoms ameliorate a gradual return
to ordinary diet should be allowed.
CHLORALISM.
The chloral habit is very easily acquired by individuals who have employed
hydrated chloral in ordinary doses for even a short time for the relief of sleep-
lessness or any other pm-pose, and, once established, produces serious results
and is difficult of cure.
Symptoms. The patient suffers from digestive disturbances and diar-
rhoea, extreme mental and physical weakness with sudden flushings due to
vaso-motor derangements, cardiac palpitation, and from erythematous
eruptions, usually purplish in color, and especally affecting the face; sometimes
they are found upon the mucous membranes. In some instances bed sores
and ulcerations appear. Dyspnoea, due to depression of the heart action and
the respiration and the general bodily weakness, is a marked symptom; the
temperature is often subnormal. The patient sleeps only when under the
influence of the accustomed hypnotic and death in collapse may at any time
follow an over-dose, since by reason of the cumulative effects of the poison
in the system the vital functions are greatly impaired and elimination is ren-
dered impossible. Sudden withdrawal of the drug may cause symptoms
analogous to those of deHrium tremens; such a condition is dangerous, as
fatty degeneration of the heart is likely to be present.
Treatment should be carried out upon the same lines as those to be described
in dealing with the morphine habit. Isolation and careful attendance are
necessary; stimulation of the heart by means of ammonia, strychnine and
digitalis is indicated; the sleeplessness may be controlled by the bromides,
sulphonmethane (sulphonal), sulphonethylmethane (trional) or veronal.
SULPHONMETHLIXE (sULPHONAL) POISONING. 305
a combination of the t-n-o last consisting of 10 or 15 grains (0.66 to i.o) of
trional to 5 grains (0.33) of veronal is often quite effectual. Morphine may
be employed only as a last resort. Tonics, plenty of nourishing food and
congenial occupations, together with electricity and massage are useful adjuncts
to treatment.
SULPHONMETHANE (SULPHONAL) POISONING.
Fatal instances of poisoning by sulphonal have been reported as occiirring
from small doses of this drug continued for long periods. The excretion of
this substance seems to be slower than its absorption and consequently there
is a tendency to a cumulative action. This may lead to gastritis, renal disease
and certain not very clearly understood changes in the blood. As a result
of the last there is a characteristic discoloration of the urine due to the presence
in it of a reddish-brown pigment, hsmatoporphyrin, which is an iron-
free product of tlie decomposition of hEemoglobin. This occurs chiefly
in women and is associated with constipation, vomiting and gastric pain,
weakness and ataxia, confusion and partial paralysis; eventually suppression
of the urine, collapse and death may result. Though the continued use of the
drug may not induce these grave manifestations it may be attended by severe
functional distiorbances such as mental, moral and physical deterioration,
indigestion, impaired nutrition and cutaneous eruptions.
Enormous single doses have been known to cause paralysis of the sphincters,
anuria, subnormal temperature and, as a late symptom, respirator}' depression.
Treatment. The untoward effects of sulphonal can usually be avoided by
intermitting its administration from time to time and by the daily use of the
alkaline mineral waters either still or carbonated. ^Vhen toxic symptoms
have appeared the drug should be stopped at once. The treatment otherwise
is symptomatic and supportive.
SULPHONETHYLMETHANE (TRIONAL) POISONING.
The symptoms resulting from the continued use of trional are analogous
to those of sulphonal poisoning. They consist of hebetude, drowsiness,
anorexia, and muscular weakness; the frequency of the pulse is diminished
and, in marked instances, vertigo, ataxia and more rarely hallucinations
and delirium may be obser\-ed. Haematoporph}Tinuria occurs and upon
its appearance the administration of the drug should be stopped.
Treatment consists, as in sulphonal intoxication, of the employment of
means to favor elimination and to support the patient. The symptoms
should be combated as they arise by the indicated measures.
20
3o6 THE INTOXICATIONS.
VERONAL POISONING.
A few instances of poisoning due to this drug have been reported. In
one patient its administration resulted in a febrile movement which lasted
about a week, dryness of the mouth, a morbilliform rash upon the face, chest
and arms, which later became confluent and was followed by a vesicular and
bullous eruption upon the mucous membrane of the mouth and pharynx,
conjunctivitis and aural pain. A dose of 24 grains (1.66) has produced the
sympto9is of narcotic poisoning followed by a universal cutaneous erythema
which recurred after a second dose and in addition the patient suffered from
periodic delirium.
The prolonged employment of veronal may result in the appearance of