You cannot look at a stranger and say with confidence from his appearance that he is an alcoholic. It is easy to tell that a man is drunk but not that he is an habitual drinker. Yet continued excessive drinking does produce bodily changes and these in turn result in illnesses both physical and mental.
From the somatic standpoint the most serious consequence of alcoholism is malnutrition. This arises in two ways.
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The chronic alcoholic does not eat enough and what he eats does not nourish him as well as it should. He does not eat enough partly because his earnings may be small but chiefly because he redistributes his spending so as to buy more and more drink and consequently less and less food. Drinking becomes a more pressing necessity than eating. Also, he is frequently forced to fend for himself because his wife and relations have left him. His knowledge about cooking and the facilities for it are both probably inadequate so he will fall back on the comparatively expensive practice of buying prepared foods. His diet will be excessively starchy and considerably deficient in protein. If he takes his food in pubs so as to be able to drink at the same time he is likely to subsist chiefly on rolls, potato crisps, and occasional sausages. The high price of food in public houses constitutes a further economic setback. He will get enough in sheer calories, however, because of the alcohol. Besides the protein lack, such a diet is deficient in vitamins, particularly in vitamin B.
These considerations apply more to the poor than to the rich alcoholic. But even he is likely to suffer from missed meals and from self-induced restrictions of diet because his appetite has gone. He prefers to forgo solid for liquid refreshment.
The lack of appetite (anorexia) is often accompanied by morning nausea which leads to giving up breakfast; during the day the constant supply of alcoholic calories between meals reduces feelings of hunger, and the effect of an inflamed stomach (gastritis) or of a diseased liver (cirrhosis) is to produce further anorexia. These factors, independently or in concert, may result in an even more serious nutritional deficiency for, when they operate, food may not be properly absorbed from the intestines or metabolized for the body's use. Ultimately a vicious circle is set up. Malnutrition itself contributes to cirrhosis of the liver, resulting in further malnutrition. Once the alcoholic reaches a certain stage of physical change his further decline is generally rapid.
Chronic alcoholism is the commonest cause of liver disease. We cannot be sure whether the alcohol exerts a direct toxic effect on the liver cells or whether the poor absorption of food from the intestine and the poor diet together produce an insufficiency of some substances essential to the liver's good repair. The important thing is that chronic alcoholics frequently suffer from liver disease which may in its early stages be mild and reversible but which, if unchecked, can progress to the severe form which is called cirrhosis (because of the scarring and hardening which the liver undergoes). The chief clinical features are a feeling of illness (liverishness is the name given to its mild form), flatulence, anorexia and sallowness of the skin. About a third of all cases develop jaundice. Dropsy and vomiting of blood may both occur late in the disease, which kills about half of those who suffer from it.
Before he develops cirrhosis the alcoholic is likely to suffer fairly severely from gastritis. Indeed some purely social drinkers are affected by this condition to such an extent that the pain and flatulence actually stop them from drinking any further on particular occasions. The inflammation of the stomach from which the condition gets its name is caused directly by the irritant property of strong drinks; spirits cause it more than beer or wine. The stomach's blood-vessels become dilated so that the whole lining is suffused with blood and covered in mucus. In addition, the stomach ceases to contract normally but distends, giving rise to discomfort and flatulence. Gastritis is the simplest of all the alcoholic conditions to cure. It goes away quickly once drinking stops.
The remaining physical illnesses brought about by chronic alcoholism are borne by the nervous system. An important cause is malnutrition resulting in a deficiency of one or more of the B vitamins. This is responsible for a common condition, peripheral neuritis. The nerve fibres bear the brunt of this condition and the longer nerves, those which stretch all the way from the spinal column to the ends of the limbs are the most involved because their need for vitamins is greatest. Hence the neuritis is ‹“peripheral'. It mainly affects the toes and the feet, the fingers and the hands, beginning with a sensation of tingling, pins and needles, and progressing to numbness. Because the nerves to the skin are affected the sufferer cannot finely assess what he is touching and may not know that there is anything in his hand if he does not look. He cannot appreciate ups and downs in the surface he walks upon and feels that he is treading all the time on cotton-wool. In a late stage the nerves to the joints become damaged so that the patient may no longer know the positions that his feet or hands are in. Consequently he keeps on falling. The sensory nerves are affected earlier than those responsible for muscular movement, but as the condition progresses these also suffer and weakness develops, first in the extremities and later spreading towards the trunk. Peripheral neuritis requires treatment in bed. Vitamin B therapy is necessary and it may take many months before recovery is complete.
These physical ravages of alcoholism occur, for obvious reasons, late in its course. If treatment is not commenced and vigorously carried out, the patient (for by this time a patient he certainly is) is likely to pursue a progressive downhill course towards invalidism and death. Fortunately he can no longer evade medical attention and, provided that his physician does not enter into a covert conspiracy with him to gloss over the true nature of his condition, he may be persuaded into accepting treatment to make him give up drinking.
So far we have discussed the damage done to the body by excessive drinking. We must now turn to abnormal mental states which arise from the effects on the brain of prolonged excessive intake. Mental symptoms of chronic alcoholism may be caused in three ways; they may occur as withdrawal symptoms or from vitamin deficiency or from destruction of brain cells.
Withdrawal symptoms are brought about by stopping drinking or by a sudden drastic reduction in the amount taken. In consequence there is a rapid drop in the concentration of alcohol in the blood. Heavy drinkers of some years' duration, who maintain a very high alcohol intake continuously for some days or weeks before stopping, are sensitive to this reduction in concentration and develop symptoms. The same symptoms which follow alcohol withdrawal can also be produced by the sudden cutting off of barbiturate sleeping tablets by anyone who has been heavily overdosed for some time. Because of this similarity in withdrawal symptoms, alcohol and barbiturates are classified in the same group of addictive agents.
Symptoms occur anything from a few hours to a few days after stopping drinking. Milder symptoms begin earlier; delirium tremens, the most severe, begins late. The earliest and commonest withdrawal state is acute tremulousness. This is what physicians call it but alcoholics know it as ‹“ the shakes ‘ It follows so soon upon reduction in heavy drinking that it may in fact come on before drinking has completely stopped. Usually, however, it takes a few hours to develop and many alcoholics are consequently affected by it each morning. ?When I wake up I T-b have to take a drink to steady myself' is a common complaint. In this state the alcoholic is agitated, jumpy and easily startled. The principal feature is gross shaking of the hands, made worse if he tries to do anything with them. Sometimes he complains of feeling shaky inside. There is anxiety, physical restlessness and a feeling of weakness. Agitation and tremor can reach such a degree that he may not be able to sit still, to dress himself or to pour out a drink without spilling it. Usually the condition disappears fairly rapidly as more drink is taken but without alcohol it may persist for as long as a week or more. More severe forms of alcoholic tremulousness occur in spree drinkers after many days of unrelieved drinking; the continuous drinker is usually subject to milder forms. A quarter of those who suffer moderate or severe attacks have accompanying hallucinations. These are usually short-lived and may only be admitted to after they have ceased to be experienced. Then the alcoholic says that he had a vivid nightmare which was difficult to disentangle from reality. The hallucinations may be visual or auditory. Things around him may appear distorted in shape; shadows seem to be real and to move. Shouting or snatches of music may be heard and he may also misinterpret innocent remarks of bystanders whether they are addressed to him or not. If the alcoholic is examined at this time, especially if he is in the unfamiliar surroundings of a hospital or police station, he may have a little difficulty in orientation, in conveying where he is and what time it is.
Delirium tremens is one of the most dramatic conditions in the whole calendar of medicine. To the observer there is a rapidly changing picture of bewildering, disordered mental activity. It is difficult for him to realize that for the sufferer every conscious moment is one of extreme fear. Fear, agitation and great distractibility are the dominant features, although disorientation and hallucination are the most vivid. Delirium tremens -DTs – generally begins two to five days after stopping very heavy drinking. It may be the first manifestation, though frequently the state of alcoholic tremulousness passes imperceptibly into it. There have usually been at least ten years of excessive drinking before the first attack.
The symptoms are florid. There is great restlessness and agitation. In the hospital ward the patient, weak as he is, may have to be restrained by two or more people before he can be got into bed. He is never still, tossing and turning restlessly, constantly engaged in conversation, switching from person to person, from subject to subject at the smallest stimulus and frequently shouting salutations and warnings to distant passers-by. His hands, grossly tremulous, clutch at the bedclothes; con-tinously he tries to pick from them imaginary objects, shining silver coins, burning cigarettes, playing cards, or bed bugs. He is a prey to ever-changing visual hallucinations and may shield his face from menacing attacking obj ects, animals or men. At any moment his attention can be distracted by a chance gesture or remark made by someone round him. His pupils are frequently dilated and his ceaseless exertions have given him a rapid pulse and sometimes a fever.
He is completely disoriented. He may not know where he is, the time of day, the date or even the month. He misidentifies people, thinking for instance that the nurse is a waitress. At one moment he will fail to recognize familiar people, at another he will greet strangers as old friends, calling them by name and, if induced to do so, inventing the circumstances of their last meeting. He is intensely suggestible and readily responds to the promptings of his examiners so that, for example, he may be induced to tell the time from a blank circle if he is told that it is a clock. The patient is completely confused.
The prevailing mood is one of frightful apprehension which arises predominantly from his misperception and misrepresentation of his surroundings. He feels he is being threatened from all sides and that he must fight to ward offhis attackers. But why does his mind react in this way? It is because the ego, the executive part of the self, cannot perform its functions when there is acute disorganization of the brain. The alcoholic has been coping with the sensed disapproval of other people for a long time and in his confused state now acts on fears and suspicions which he normally represses.
There is no need to inquire about hallucinations. Their presence is only too apparent. The patient responds to imaginary voices and reacts to imagined sights. He sees, in particular, rapidly moving small objects. Rats and mice are traditionally described but often the animals are far more threatening – big black flies buzzing at the face, cats coming to claw at him. Sometimes the hallucinations are more bizarre: ‹“ Zip-fastening suitcases biting at my legs ‘ said a recent patient. Sometimes the fear changes to resignation – ‹“I know you're going to kill me: get on with it. Sometimes there are moments of bonhomous joviality when he will offer drinks all round; but it is not long before the fear reasserts itself. No words can do justice to the picture of fully developed delirium tremens during the hours or days before the patient falls exhausted into a deep sleep. He generally emerges from this little the worse and with his memory for the recent events mercifully blunted.
Unchecked, the condition usually takes three or four days to run its course but fortunately it can now be considerably modified by drugs. Deaths still occur, largely as a result of other illnesses present at the same time. Since the delirium is a withdrawal reaction we have to ask why the drinking was stopped. Usually this is because something made it impossible for the alcoholic to keep up his supply. Often a man is admitted to hospital with an illness, such as pneumonia, or with an injury following an accident. Unless it is realized that he is an alcoholic and, therefore, the possibility of his developing delirium tremens is anticipated, the subsequent enforced withdrawal of alcohol will not be compensated for by appropriate medication. About three days later the physician or surgeon will be presented with a case of delirium tremens. If the possibility is borne in mind, however, an attack can be averted completely.
Delirium tremens is correctly treated with large doses of tranquillizing drugs such as chlorpromazine.
Alcoholic epilepsy, when it occurs, follows within a day or two of stopping drinking. Fits can be provoked in anybody, but the difference between the normal person and the epileptic is that, whereas the former needs a strong artificial stimulus, such as the injection of certain drugs, before he has a fit, the brain of the epileptic undergoes the requisite electrical discharge spontaneously or with a minimal upset to trigger it off. The difference is essentially a quantitative one. The effect of alcohol (or, to be precise, of alcohol withdrawal) is to increase the susceptibility of the brain to undergo spontaneous electrical discharges resulting in fits. There may be single seizures or bursts. They are generally major convulsions in which consciousness is lost and they have to be managed in the same way as other forms of symptomatic epilepsy.
The knowledge that these states, alcoholic tremulousness, alcoholic epilepsy, and delirium tremens are phenomena resulting from alcoholic withdrawal is comparatively recent. Two pieces of research have been decisive; first, meticulous observation of the timing of their onset in relation to the end of drinking and secondly the production of similar states following the sudden withdrawal of barbiturates.
Chronic alcoholics are likely to be deficient in vitamin B. This lack causes other mental disorders which are not the result of alcohol withdrawal. One is a severe disturbance of memory. In this state consciousness is not impaired and there is no confusion but the condition is commonly first noticed as an attack of delirium tremens is ending. The memory loss is selective andis best described in the account given in 1877 by the Russian psychiatrist Korsakov, by whose name the amnestic syndrome has long been called.
In these cases disorder of memory manifests itself in the form of a remarkably peculiar amnesia (memory loss) in which the memory of recent events is disturbed, whereas long past events remain remembered quite well. Mostly the amnesia of this particular type develops following prodromal agitation with confusion. This agitation lasts several days, and then the patient becomes calm again. His consciousness clears; he appears to be in better possession of his faculties; he receives information correcdy, yet his memory remains deeply affected. On first contact with the patient one may not note the presence of psychiatric disorder. The patient impresses one as in possession of all his faculties; he reasons perfectly well, makes correct deductions from given propositions, jokes, plays chess or a game of cards; in short, comports himself as a psychically normal person. Only after a long conversation one may note that the patient confuses events, that he remembers absolutely nothing of what happens around him. He does not remember whether he had his dinner, or whether he got out of bed. At times he forgets what occurred just an instant ago. You have come into his room, conversed with him, and stepped out for a moment. You return, and the patient has no recollection that you have talked to him a moment ago. Persons whom the patient learns to know only in the course of the disease, e.g. his doctor or nurse, he cannot remember, and he assures them that he sees them for the first time. However, he remembers quite accurately past events which occurred before the illness.
It is almost unbelievable how short-lived the patient's memory can be. One patient awoke each morning believing he had been admitted to hospital during the previous night. Another, after weeks in the ward, still required to read the names at the foot of each bed in order to find his own when returning from the lavatory. Yet so well were his other faculties preserved that, failing to remember investments, he had lost a fortune as a stockbroker over the past few months without anyone realizing he was ill. To compensate for the memory loss the patient confabulates; he invents circumstances to fill the gaps and to cover up. The doctor can readily induce such confabulations by suggestion. In addition to the memory loss, or perhaps because of it, intelligence suffers. Problem-solving in both the actual and the psychological test situation is not so well performed as formerly. Once the amnestic syndrome has developed it is not possible to reverse it completely though considerable recovery of memory may slowly occur with correct medication.
In another condition, Wernicke's encephalopathy, there is great difficulty in concentrating and slowness in answering questions although consciousness is full. It is frequently but not invariably associated with a memory loss of the Korsakov type. There is also a paralysis of some of the movements of the eyeball and frequendy a disturbance of gait and balance. This condition is associated with pathological changes in particular areas in the base of the brain. It also is due to deficiency of vitamin B.
A number of chronic alcoholics show evidence of a continuing decline in intelligence as their drinking years progress. This is known as alcoholic dementia. Insidiously there is a falling off in their intellectual ability. They become less perceptive of what goes on around them, less capable of subtle evaluation of their experiences and they are handicapped in their ability to convey their meaning to others. New and complicated tasks seem harder to perform and consequently less inviting. They become duller. This is gradually perceived by their relatives and associates but is accepted as a behaviour change rather than as evidence of intellectual loss. Psychological tests reveal the true nature of this state because they provide evidence of organic impairment of intelligence. The condition is due to destruction of brain cells. When the impairment is gross the patient may be incapacitated and have to stay permanently in a psychiatric hospital. We know now that this is due to brain disease rather than, as Victorian moralists and physicians were wont to believe, an expression of moral degeneration. Dementia is by no means an inevitable consequence of chronic alcoholism. When present it is irreversible but the majority of chronic alcoholics who have been successfully treated are able to live full and energetic lives without any evidence of intellectual impairment.
All the foregoing conditions are unquestionably organic in aetiology. They are caused by chemical or structural abnormalities in the brain. But other psychological conditions are found which have not been shown to have an organic basis. These are called ‹“functional' disorders. This name puts them in line with the majority of psychoses unrelated to alcohol, and these they in some measure resemble. There is still controversy whether, when these conditions develop in an alcoholic, the drinking was their cause or merely their first manifestation. Such doubts cannot be altogether resolved and it is wiser just to describe the conditions rather than to attempt authoritative explanation.
The first of these is pathological jealousy. Generally affecting men but sometimes women too, the jealousy is directed towards the spouse, who is believed to be unfaithful. Pathological jealousy goes far beyond normal jealousy. Fleeting suspicions which can be easily resisted are commonly described by alcoholics; the wives may not be distressed by the observant attention which their husbands give them. As jealousy becomes more intense the alcoholic may still retain the ability to question his suspicions, although these are now disturbing enough to him to feature as a symptom (see page 101). In some cases belief in the spouse's infidelity reaches delusional force. It may not be overcome by reasoning, and resists clear-cut evidence which rebuts specific allegations. The jealous husband seizes upon any chance remark that his wife makes, any passing glance she may receive from a man, to feed his suspicions. He searches her handbag for letters and her clothing for tell-tale signs. Of course, he disbelieves her protestations and frequently not only upbraids her but beats her for her supposed adultery. Her lot may become unbearable, yet so limited is the field of her husband's delusions and so rational is he in every other particular that it is next to impossible to order his compulsory detention in hospital. Needless to say, he will not go voluntarily. Separation is often the only practicable course, although its immediate effect is to fan the flame of suspicion. Divorce courts frequently hear testimony of pathological jealousy and it may result in murder. Why this condition should be particularly associated with alcoholism is a mystery. Psychoanalysts maintain that pathological jealousy is a manifestation of disguised homosexuality. It is a defence for the patient against the recognition of his own inclinations and at the same time, covertly, a gratification of them. Heprojectsontohis wife his own unrecognized feelings for the other man. Once pathological jealousy has reached the stage of delusions the outlook for recovery is not good. Some patients develop an illness resembling schizophrenia. However, less extreme forms of jealousy commonly fade if the patient gives up drinking.
Another psychotic condition is alcoholic hallucinosis. The patient, who is fully conscious, hears voices which, characteristically, are talking about him in obscene language. The hallucinations may clear up if he stops drinking, but not necessarily; sometimes, even with abstinence, they continue for years. One patient, a bookmaker, described how he had been ‹“on the line' to such voices for ten years, during which time he had been able to continue working and drinking. When he gave it up they stopped but when he relapsed they returned and although he was subsequently enabled to remain teetotal they persisted. Auditory hallucinosis of this sort is quite different from the vivid, transient and disorganized hallucinations that occur with alcoholic tremulousness or with delirium tremens.
I clearly heard a conversation between my mother and my domestic help, which I thought was taking place outside the kitchen. Throughout the day, I frequently asked members of the household to repeat what they had just said as I had not heard it properly, only to be told that no one had uttered a word. I frequently heard my husband's voice calling me, as if he were upstairs or in the hall.
The next day I was defrosting my refrigerator when I distinctly heard my husband in his office, which is completely away from our house. I heard him having consultations with three different people, then dictating letters and talking to his secretary. It seemed to me that I was actually hearing what was happening at that precise moment.
During the early afternoon I was most disturbed to hear a strange male voice which was loud and clear, and claimed to be my conscience. By this time I was in a state of agitation; I sincerely believed this to be my conscience rebuking me. I was getting absolutely no peace from this voice, which was accompanied by music, and a mixed choir all of which had the quality of what I would call Church music. After the evening meal was over this became so loud and persistent that I felt anyone in the room with me could not fail to hear it as well as I was receiving it. Therefore I escaped by myself on every possible occasion and even found myself talking aloud in reply to this ‹“conscience'. My husband became very curious as to the reason for my frequent disappearances and, in the end, I took him into my confidence. As the evening wore on, the nature of the voice and music changed completely and became almost raucous. The voice introduced himself as ‹“Jimmy Young' from Glasgow, my hometown. I have never at any time in my life known anyone by this name. The tone of voice at times was very polished, but sometimes it assumed a very decided Glasgow accent. Gradually it became louder and louder, and almost mocking and jeering at me, to the extent that I became angry with myself for being so taken in as ever to believe this could be my conscience. I began to be convinced that this was some extraordinary type of radio wave which some cranks had been able to ‹“tune' in to me.
This patient recovered completely. Unfortunately not all patients do.
There is no evidence to incriminate any organic process. The condition of alcoholic hallucinosis is neither a withdrawal symptom nor due to a vitamin deficiency but is much more closely related to schizophrenia and, if it persists, it cannot be distinguished from that disease except by the history. Fortunately it is not common.