[Reprinted from The Medical News, July 2, 1892.] A BRIEF SUMMARY OF THE CLINICAL HISTORY AND T REATMENT OF TWO THOUSAND AND TWELVE CASES 0F ALC0H0LISM, OF WHICH EIGHTY-SEVEN WERE MANIACAL.1 By THOS. S. LATIMER, M.D., OF BALTIMORE. In the spring of 1891, at a meeting of the Johns Hopkins Hospital Medical Society, I reported 958 cases of alcoholism occurring at the Baltimore City Jail, between April 11 and December 30, 1890, of which 40 cases were of mania a potu, with an average duration of mania of forty-eight hours. In these cases no distinction was made between mania a potu and delirium tremens. They were simply cases of mania due to alcoholic excess, ac- companied in most instances by hallucinations of abhorrent nature, with tremors, great feebleness, loss of appetite, vomiting in many cases, and in- ability to sleep. In the non-maniacal cases, all of the symptoms related were uniformly present (in- cluding tremor) except the mental disturbance. All were treated with potassium bromide ; the maniacal cases with thirty-grain doses every two hours, and the non-manical with the same dose at intervals of 1 Read at the Seventh Annual Meeting of the Association of American Physicians, held at Washington, May 24, 25, 26, 1892. 2 LATIMER, four hours. No addition was made to this treat- ment, except in three or four cases in which ten drops of tincture of digitalis and five grains of ammonium carbonate at intervals of three hours were also given ; all recovered. Since reporting these I have had opportunity to observe in the same institution 1054 additional cases, of which 47 were maniacal. This report, therefore, may be said to be a brief history of the gross clinical features and treatment of 2012 cases of alcoholism, of which 87 were maniacal. No at- tempt is here made to discuss the pathology of alcoholism, or any of the symptoms, except those directly connected with the debauch in the habitual drinker. No reference is therefore made to symp- toms presumably due to persistent hepatic, renal, or peripheral nerve-lesions. Nearly all of these patients were arrested for drunkenness and disorderly conduct. They were technically called " peace cases," to imply that they were arrested for breaking the peace. A majority of them were also what in the jail are called "reg- ulars," from the regularity with which they were returned after very brief absence. Two noteworthy facts are contained in the foregoing statement: 1. The cases were all drunk when arrested, and many of them had not yet become sober when brought to jail. 2. They were cases of almost continuous drunken- ness, culminating at short intervals in a severe de- bauch, leading to some act of violence, or to a condition of drunken stupor, in which they were TREATMENT OF ALCOHOLISM. 3 picked up on the streets quite helpless and almost or quite unconscious. It was also quite common for my hospital steward to say, " Doctor, this man, or woman, is a chloral- fiend," or an "opium-fiend," or a "cocaine-fiend." Indeed, the cases were quite indifferent as to the par- ticular intoxicant, using one or the other as chance might determine. All used some form of alcohol when obtainable, but many were habituated to the use of other intoxicants of the class mentioned. This fact primarily determined the choice of the remedy uniformly directed. It will be observed that here was a particularly unfortunate class of cases to treat. All, even though young in years, were old sots ; many had had num- erous attacks of mania a potu ; many were addicted to the use of intoxicant drugs; many were the sub- jects of chronic alcoholic lesions, and of other loathsome and enfeebling diseases indirectly con- nected with their mode of life. They were, as a class badly fed, badly clothed, and badly housed, when not in jail or in the almshouse, and certainly no luxuries were furnished them at either of these places. Almost without exception, even with those that were not at any time delirious, they were with- out desire for food, often nauseated, sleepless, full of pain, muscular and articular, tremulous in tongue, hands and legs, and full of nameless terror. In no single instance that I remember was the appetite for stimulants lost. Almost invariably the victims begged piteously for drink, which in no case was given them. The jail-fare consisted of weak coffee, with coarse 4 LATIMER, brown-bread for breakfast; some kind of soup, not very rich, with plenty of brown-bread and a chunk of poor meat that had been boiled with the soup, for dinner; no supper. The cases slept in locked cells on sacks of straw on iron bedsteads without blankets, even in the quite cool weather of spring or fall. No pneumonic or pleuritic complications ensued from this exposure. The second series of 1054 cases, of which 47 were maniacal, presented substantially the same history, were treated in the same manner, and with the same result. Besides these, two fatal cases occurred. In one instance, the patient was brought in after my daily rounds, in a condition of alcoholic coma, and died before I saw him. He was supposed by the officers of the jail to be in that heavy drunken sleep so common with these subjects, and was left to sleep off the effect of his potations without having been given anything whatever. He was found dead in his cell in the morning, apparently without having recovered consciousness. Whether this was a purely alcoholic effect, or if he had taken also, or alone, an overdose of chloral or morphine, or whether it was uremic coma, cannot be said, as I did not see him during life, and no post-mortem examination was permitted. The second fatal case also came in in the evening after my rounds. He was said to be quite drunk, but was able to walk to his cell, which was on the sixth tier. He became somewhat delirious in the night, but not sufficiently so to make the night- officer think it worth while to transfer him to a cell on the ground floor, where all cases with mania are TREATMENT OF ALCOHOLISM. 5 kept. In the morning, when his cell was opened, he sprang over the railing and fell to the stone pavement, receiving such injuries as to cause his death within half an hour. Neither of these deaths can therefore be fairly charged to the plan of treatment, nor are they in- cluded in the 87 cases of mania a potu, since, as I had not seen the one before death, or the second be- fore the fatal injury, I am unable properly to classify them. In the second series of cases 4 were charac- terized by great mental excitement, noise, and violence, without terrifying delusions. They, like all of the rest, had been drinking up to the time of arrest, and were given no alcohol after arrest. Of the second series 13 (of 47) were admitted with delirium tremens, and in the remainder (34) delirium developed after admission-in one case as late as seventy-two hours after. In no case did the delirium last more than five days. The average period at which these patients were enabled to do some kind of light work was about two days after treatment was begun; they were not then in such condition as to be declared convalescent, or, if they had been in private practice, to be allowed to leave the house ; but here, where they were under constant observa- tion, and where no opportunity to obtain drink existed, they were allowed to do such work as they desired, and all drugs were then generally stopped. Usually on the second night, but often not until the third, they slept fairly well; and by this time they also began to eat with apparent relish the coarse prison-fare. Food was offered them at each meal, but no attempt was made to urge it upon them if 6 LATIMER, inclination did not prompt them to eat. In a very few instances, milk, eggs, light bread and tea were substituted for the regular prison-fare, but these were seldom taken, and were usually withdrawn when appetite returned and a good sleep had been had. No distilled or fermented drink was given in any one of these cases-no drug but potassium bromide, except in a few instances, in which great cardiac weakness prompted the use of tincture of digitalis (ten drops) and ammonium carbonate (five grains), or occasionally in very noisy subjects, in which morphine (one-fourth grain), and atropine (one one- hundredth grain), were administered hypodermati- cally, at night. Thus, it is seen that in 2012 cases of chronic alcoholism with acute explosions, 87 of which were maniacal, under circumstances of the most depressing character, all did well without the use of alcoholic stimulants. My conviction is strong that it was to the withholding of the alcohol, rather than to the administration of the drug, that the good results obtained were primarily due. No re- straint, further than keeping the patients in a locked cell while delirious, was exercised. The patients walked their cells incessantly, and often destroyed the bedding in pursuit of imaginary enemies ; but as it was of but little value they were allowed to do so, rather than bind them in bed, or even secure the hands. As the patients were usually alone at night, in a dark cell, I found that when they were bound it added greatly to their terror, and intensi- fied the maniacal symptoms. I am moreover con- vinced that the unceasing walk, with its resulting TREATMENT OF ALCOHOLISM. 7 weariness, tended to the induction of sleep at an earlier period than would otherwise have been the case. In no instance, beyond a few slight bruises, did any harm result from the absence of bonds. I have not observed that alcoholics are ever disposed to in- jure themselves. When injury is sustained it is in flight from imaginary evils, or in struggling to obtain rink. All attempts to secure the patient in bed, to bind or muffle the hands, are unnecessary. If he is securely locked in a cell, or by himself in a room, made bare of all superfluous articles, he is unlikely to harm himself. Friends or attendants within call or sight reassure him when his hallucinations are terri- fying, but he needs no restraint from them, and may be allowed to wander about his apartment without let or hindrance, with advantage to himself, pro- vided the windows are secure. I have treated a number of cases of delirium tremens in private practice and in hospitals during the period covered by this record, but not with such results. Fatal cases are not uncommon in hospital, and almost as frequent in private practice. This I believe is mainly attributable to the fact that neither at home nor in a general hospital is it possible to withhold stimulants or such drugs as morphine and chloral, from consideration of other inmates of the home or ward. It must be remembered, however, that cases are usually carried to hospital for some disease-complication, whilst the merely drunken and disorderly are taken to police-stations and thence to jail. Before closing this short report it may be well to add that nearly all of the cases considered were 8 TREATMENT OF ALCOHOLISM. committed to jail for thirty days ; this brief period of enforced abstinence exerted no appreciable in- fluence on the disposition to the intemperate use of strong drink, since the cases almost invariably returned in from one to three months, and often within as many days, after release. The study of the foregoing cases leads me to the following conclusions : 1. That the clinical phenomena attending excesses in the use of alcohol are the direct result of over- stimulation, and are not due to the abrupt with- drawal of the stimulus. 2. That though ability to swallow and retain stimulants is frequently wanting, the desire for them almost uniformly persists. 3. That alcohol in any form or quantity is unne- cessary in the treatment of such cases, and is usually hurtful. 4. That the absolute and immediate withdrawal of alcohol is of the first importance in the treatment of all of the symptoms due to its excessive use, even in cases characterized by great feebleness and ina- bility to partake of food. 5. That forced feeding is rarely necessary, and is of doubtful utility in most cases. 6. That for the protection of the patient no kind of bonds is called for, and, when necessary, for the protection of others, or for the contents of the room, they injuriously affect the mental state of the patient.