Alcoholism In The Medical Casebook

 

No alcohol:

“A patient dismayed at his doctor’s advice not to drink any alcohol while recovering from a cold.” [30]

This Week

We are going to move from cocaine to alcohol. Alcoholism was a significant problem in the Victorian age, and we will see how Sir Arthur Conan Doyle was directly affected by the impact of alcoholism in his family.

 

Alcoholism

Alcoholism + Sherlock

This is another chapter where I have had to be selective with my choice of excerpts. The term “alcoholism” is not used in the stories, but there are lots of references to drunkenness. I have decided to include passages that I feel refer to characters with alcoholism – that is chronic alcohol problems affecting their life and character.

Arthur Conan Doyle’s father, Charles Altamount Doyle, suffered from alcoholism and depression. He was an illustrator, but became unable to work due to his health. In 1881, when Arthur would have been at medical school, Charles was placed in Blairerno House, Kincardineshire, which was wonderfully described as a “house for intemperate gentleman”. He sadly continued to obtain alcohol, and had to be sectioned, and spent the rest of his life in mental asylums. Thus alcoholism would have likely been an emotive subject for Arthur. 

As in several of our chapters so far, we start with “A Study In Scarlet”. Enoch Drebber turns to drink, maybe due to guilt at the death of Lucy Ferrier, more likely due to fear that Jefferson Hope is seeking revenge. Which is a correct fear, as Hope is tracking Drebber and his ally, Joseph Stangerson.

“They were very cunning, though. They must have thought that there was some chance of their being followed, for they would never go out alone, and never after nightfall. During two weeks I drove behind them every day, and never once saw them separate. Drebber himself was drunk half the time, but Stangerson was not to be caught napping. I watched them late and early, but never saw the ghost of a chance; but I was not discouraged, for something told me that the hour had almost come. My only fear was that this thing in my chest might burst a little too soon and leave my work undone”. 

We learnt in our Aortic Aneurysm chapter how Hope eventually manages to abduct Drebber by impersonating a cabbie.

“ ‘It’s infernally dark,’ said he, stamping about.“

“ ‘We’ll soon have a light,’ I said, striking a match and putting it to a wax candle which I had brought with me. ‘Now, Enoch Drebber,’ I continued, turning to him, and holding the light to my own face, ‘who am I?’ ”

“He gazed at me with bleared, drunken eyes for a moment, and then I saw a horror spring up in them, and convulse his whole features, which showed me that he knew me. He staggered back with a livid face, and I saw the perspiration break out upon his brow, while his teeth chattered in his head. At the sight, I leaned my back against the door and laughed loud and long. I had always known that vengeance would be sweet, but I had never hoped for the contentment of soul which now possessed me.”

We will return to this scene in our very next chapter.

In “The Sign Of The Four”, alcohol problems crop up in a fine piece of Sherlock logical analysis involving a pocket watch previously owned by Watson’s elder brother.

“It is very customary for pawnbrokers in England, when they take a watch, to scratch the numbers of the ticket with a pin-point upon the inside of the case. It is more handy than a label as there is no risk of the number being lost or transposed. There are no less than four such numbers visible to my lens on the inside of the case. Inference – that your brother was often at a low water. Secondary inference – that he had occasional bursts of prosperity, or he could not have redeemed the pledge. Finally, I ask you to look at the inner plate, which contains the keyhole. Look at the thousands of scratches all round the hole – marks where the key has slipped. What sober man’s key could have scored these grooves? But you will never see a drunkard’s watch without them. He winds it at night, and he leaves these traces of his unsteady hand. Where is the mystery in all this?”

We next return to “The Five Orange Pips”, where Elias Openshaw deals with the terror of receiving the orange pips by using alcohol.

“I could see a change in my uncle, however. He drank more than ever, and he was less inclined for any sort of society. Most of the time he would spend in his room, with the door locked upon the inside, and sometimes he would emerge in a sort of drunken frenzy and would burst out of the house and tear about the garden with a revolver in his hand, screaming out that he was afraid of no man, and that he was not to be cooped up, like a sheep in a pen, by man or devil. When these hot fits were over, however, he would rush tumultuously in at the door and lock and bar it behind him, like a man who can brazen it out no longer against the terror which lies at the roots of his soul, At such times I have seen his face, even on a cold day, glisten with moisture, as though it were new raised from a basin.”

In “The Adventure Of The Blue Carbuncle”, alcohol problems again appear in a piece of Sherlockian deduction, on this occasion involving a hat.

“Then, pray tell me what it is that you can infer from the hat?”

He picked it up and gazed at it in the peculiar introspective fashion which was characteristic of him. “It is perhaps less suggestive than it might have been,” he remarked, “and yet there are a few inferences which are very distinct, and a few others which represent a strong balance of probability. That the man was highly intellectual is of course obvious upon the face of it, and also that he was fairly well-to-do within the last few year, although he has now fallen upon evil days. He has foresight, but less now than formerly, pointing to a moral retrogression, which, when taken with the decline of his fortunes, seems to indicate some evil influence, probably drink, at work upon him. This may account for the obvious fact that his wife has ceased to love him.”

We then get a page-long explanation for his deductions. The hat has been neglected, and no loving wife would allow a husband out in such a state!

In “The Adventure Of The Copper Beeches”, a governess, Violet Hunter, takes up a post at the mysterious home of the Rucastle family. One of the first signs that something is amiss is the odd way the poor behaviour of the servants, the Tollers, is tolerated.

“I shall try not to miss anything of importance. The one unpleasant thing about the house, which struck me at once, was the appearance and conduct of the servants. There are only two, a man and his wife. Toller, for that is his name, is a rough, uncouth man, with grizzled hair and whiskers, and a perpetual smell of drink. Twice since I have been with them he has been quite drunk, and yet Mr. Rucastle seemed to take no notice of it. His wife is a very tall and strong woman with a sour face, as silent as Mrs. Rucastle and much less amiable. They are a most unpleasant couple, but fortunately I spend most of my time in the nursery and my own room, which are next to each other in one corner of the building.”

The intrepid governess seizes an opportunity to explore a locked wing of the house.

“It was only yesterday that the chance came. I may tell you that, besides Mr. Rucastle, both Toller and his wife find something to do in these deserted rooms, and I once saw him carrying a large black linen bag with him through the door. Recently he has been drinking hard, and yesterday evening he was very drunk; and when I came upstairs there was the key in the door. I have no doubt at all that he had left it there. Mr. and Mrs. Rucastle were both downstairs, and the child was with them, so that I had an admirable opportunity. I turned the key gently in the lock, opened the door, and slipped through.”

We will return to the exciting story when we cover Brain Fever.

We have a very similar plot device in “The Gloria Scott”, where a sailor from Victor Trevor’s past, who knows of his previous nefarious deeds, is able to establish himself in the household.

“My father made the fellow gardener,’ said my companion, ‘and then, as that did not satisfy him, he was promoted to be butler. The house seemed to be at his mercy, and he wandered about and did what he chose in it. The maids complained of his drunken habits and his vile language. The dad raised their wages all round to recompense them for the annoyance. The fellow would take the boat and my father’s best gun and treat himself to little shooting trips. And all this with such a sneering, leering, insolent face that I would have knocked him down twenty times over if he had been a man of my own age. I tell you, Holmes, I have had to keep a tight hold upon myself all this time; and now I am asking myself whether, if I had let myself go a little more, I might not have been a wiser man.” 

Our penultimate alcoholism reference is our only visit to “The Adventure Of Black Peter.” Holmes investigates the death of a retired whaling captain. He is given the background of the victim by Inspector Stanley Hopkins.

“I have a few dates here which will give you the career of the dead man, Captain Peter Carey. He was born in ’45—fifty years of age. He was a most daring and successful seal and whale fisher. In 1883 he commanded the steam sealer Sea Unicorn, of Dundee. He had then had several successful voyages in succession, and in the following year, 1884, he retired. After that he travelled for some years, and finally he bought a small place called Woodman’s Lee, near Forest Row, in Sussex. There he has lived for six years, and there he died just a week ago to-day.” “There were some most singular points about the man. In ordinary life he was a strict Puritan—a silent, gloomy fellow. His household consisted of his wife, his daughter, aged twenty, and two female servants. These last were continually changing, for it was never a very cheery situation, and sometimes it became past all bearing. The man was an intermittent drunkard, and when he had the fit on him he was a perfect fiend. He has been known to drive his wife and his daughter out of doors in the middle of the night, and flog them through the park until the whole village outside the gates was aroused by their screams.”

The adventurous Conan Doyle, before completing his final year at medical school, did some unusual work experience. He spent 7 months working as a ship’s surgeon on an Arctic whaling ship, The Hope.  He is able to give the story an authentic air, in particular how you could murder someone with a harpoon.

Our final alcohol excerpt is from “The Adventure Of The Abbey Grange”, which we will look at in more detail in our Measles chapter. Again, a nasty alcoholic man is murdered.

“I am the wife of Sir Eustace Brackenstall. I have been married about a year. I suppose that it is no use my attempting to conceal that our marriage has not been a happy one. I fear that all our neighbours would tell you that, even if I were to attempt to deny it. Perhaps the fault may be partly mine. I was brought up in the freer, less conventional atmosphere of South Australia, and this English life, with its proprieties and its primness, is not congenial to me. But the main reason lies in the one fact which is notorious to everyone, and that is that Sir Eustace was a confirmed drunkard. To be with such a man for an hour is unpleasant. Can you imagine what it means for a sensitive and high-spirited woman to be tied to him for day and night? It is a sacrilege, a crime, a villainy to hold that such a marriage is binding. I say that these monstrous laws of yours will bring a curse upon the land—Heaven will not let such wickedness endure.”

Stanley Hopkins makes a similar appraisal of his character.

“He was a good-hearted man when he was sober, but a perfect fiend when he was drunk, or rather when he was half drunk, for he seldom really went the whole way. The devil seemed to be in him at such times, and he was capable of anything. From what I hear, in spite of all his wealth and his title, he very nearly came our way once or twice. There was a scandal about his drenching a dog with petroleum and setting it on fire—her ladyship’s dog, to make the matter worse—and that was only hushed up with difficulty. Then he threw a decanter at that maid, Theresa Wright; there was trouble about that. On the whole, and between ourselves, it will be a brighter house without him.”

There are maybe two themes in our eight canonical references to alcoholism. Firstly, and more evident in our earlier quotes, that alcohol problems can be an understandable reaction to difficult life events.  Our later excerpts then appear to dwell more on the impact of alcoholism on the people around the sufferer. Conan Doyle’s experience with his father meant he had personal insight into both of these aspects. It is not known what, if any, contact he had with his father after he had to be institutionalised – his writings tell us almost nothing on the subject.

Alcoholism In Victorian Times

There is plenty in the Victorian medical texts on alcohol, with a surprisingly good understanding of the harm alcohol can cause, but also regular advocacy of alcohol as a treatment. Sorting the references into a coherent and interesting section has been challenging, so I am going to take a different approach to usual in this chapter.

Thus I am going to look at:-

[1] Understanding of the impact of alcohol.

[2] Acute alcoholism [“delirium tremens”].

[3] Chronic alcoholism.

[4] Alcoholic liver cirrhosis.

[5] Alcoholic insanity.

[6] Alcohol as a treatment.

And there is a degree of overlap between the different sections.

[1] Understanding of the impact of alcohol

Alcohol has a powerful action on the nervous system; its effects vary according to the amount and frequency of the dose. When taken in a large dose its most conspicuous effects are exerted on the brain – death resulting in coma [sic]. Probably every tissue in the body is directly affected by the poison, and those tissues which have the most functional activity and which can least well bear deprivation of the normal blood supply suffer most from the deleterious effects of alcohol. Though the evil effects of drink are mostly observed in adult life, yet children do become intoxicated and may develop visceral changes due to alcohol. [5] 

I was impressed that Victorian doctors had an impressive understanding of the impact of alcohol on essentially all body systems. They were aware that alcohol caused virtually all the diseases that we know it can cause today.

 

[2] Acute alcoholism [“delirium tremens”]

This generally arises from the excessive use of strong spirits, wine or beer, but other agencies may cause almost identical symptoms – pneumonia, rheumatic fever, general paralysis of the insane, excessive mental excitement, some forms of uraemia and of diabetes, poisoning by excessive use of tea, coffee or opium. A sudden illness or a serious accident often appears to be the exciting cause of an attack in those who have indulged in hard liquors. In drunkards it is easy to overlook a pneumonia. [5]

There can be no question that mere deprivation of drink cannot induce an attack. [5]

The symptoms of delirium tremens are mostly as the name implies, mental and motor. Sensory symptoms are not pronounced, since no mention of them is made in classic descriptions. Weakness is probably due to the direct effect of the alcohol on the motor nervous centres, as the tremors most certainly are. The mental state is composed of sleeplessness, hallucinations, watchfulness, and fear – presenting a grouping which is almost pathognomonic. Sleeplessness is of the essence of the disease, but there is not simply wakefulness; the patient is constantly talking or muttering, and moving about in a busy manner. He hears voices and sees sights which have no existence for others than himself; he is suspicious, and dreads the approach of individuals to his side; his manner is eager and excited; generally he answers questions rationally, but wanders immediately afterwards to some imaginary scene. Generally his thoughts appear to be distressful and anxious; he is giving orders that relate to his business to persons who are absent; or he is devising plans to escape from some imaginary enemy; he fancies that rats, mice, or reptiles, are running over his bed, or that strangers are in his room. [5]

Formerly very large and often repeated doses of opium were looked upon as a specific for delirium tremens, but great mischief resulted from the practice. As has been before said, small doses of morphia are valuable after a free evacuation of the bowels in the premonitory stage. Chloral has been largely employed, but it is inferior to opium in its effects, and is more apt to depress the heart. When convulsions are present the bromide of potash, in half drachm or drachm dose, should be administered and frequently repeated, in addition to the morphia or chloral. [5]

When your patient recovers, you should use the opportunity of urging him to abstain entirely from all alcoholic liquors. It is of no use recommending moderation; nothing but entire abstinence will enable him to overcome his fatal propensity. [6]

Cases like those described above still happen, but we rarely see them in primary care. They tend to present as an emergency, and are admitted via A+E. It is odd that it wasn’t recognised that sudden withdrawal from alcohol is one of the main triggers for such a deterioration. It remains a serious condition, which can be fatal. Sedating drugs are still used to manage such causes, typically a quickly reducing course of a drug called chlordiazepoxide.

 

[3] Chronic alcoholism

Muscular tremor is a most important symptom of chronic alcoholic poisoning; it is most marked in the morning, and in the hands, though present also in the legs, and causes unsteadiness. Insomnia, headache, noises in the ears, vertigo, and flashes of light before the eyes, are other symptoms. There may be a slight degree of that uncertainty of purpose, cowardice, and suspicion, which are evident in delirium tremens. Morning vomiting, and morning diarrhoea, with want of appetite; venous points and lines – so-called stigmata in the cheeks; dingy, sometimes jaundiced conjunctivae, red and watery eyes, acne rosacea and hypertrophy [cirrhosis] of the nose, are often due to alcoholism. No reliance can be placed on the statements of patients who drink to excess. Obesity, especially of the abdomen, is common in beer-drinkers; dram-drinkers tend to be thin. [5]

Removal of the patient to surroundings in which he cannot obtain his poison, and in which he will obtain plenty of exercise in the open air, with regulated habits of living, are the most important points in treatment. Strychnia, quinine, and cod-liver oil, are of service. [5] 

There is not a lot in the Victorian textbooks on the treatment of alcoholism, which is not a great surprise, given that today we still struggle with its management.

 

[4] Alcoholic liver cirrhosis

Habitual spirit drinking is the cause of the common sclerosis of the liver; the multilobular sclerosis of Charcot. Hyperaemia, exudation, fibroid thickening, are the main stages in the production of the gin-drinkers or hobnailed liver. The process is very like that which causes the granular contracting kidney, and it is most frequent in middle aged males. [5]

In the first place, endeavour to put a complete stop to the habit of spirit-drinking. It is of little use to counsel moderation; you can do most good by resolutely insisting upon perfect abstinence from alcohol. If it is impossible to attain this object, you may allow some light wine, such as claret or hock, in moderate quantities. [5] 

I probably see more alcoholism in patients who drink wine than in drinkers of the other alcoholic options.

 

[5] Alcoholic insanity

As already stated, “transitory mania” may be at least directly induced by alcohol; but besides this and the much more common disease, delirium tremens, there are other disorders resulting from the same powerful agent, which have yet to be noticed. 1 Habits of intoxication, along with the ordinary symptoms of chronic alcoholism, often induce a state of mind characterized by gloomy suspicion and hallucinations of hearing. This condition has prompted to homicide as well as to suicide in a number of cases. 2 Excesses in alcohol may cause mania or melancholia of an ordinary kind, except that the delusions partake of the delirium tremens character, and that the attacks themselves are of shorter duration. Though cases of this kind are occasionally seen, they must be regarded as rare. 3 Progressive dementia, accompanied by a form of general paralysis, is a rather common result of prolonged drunken habits. It not infrequently occurs in women who have been long addicted to secret tippling. 4 There remains the condition known as dipsomania or oinomania. The craving for drink in this state is insatiable, and no consideration whatever deters the victim from seeking its gratification. [15]

Great moral depravity is generally a marked feature of character; and the writer has observed that in women this is usually associated with much pretence or show of religion. The periodic variety is not common. It occurs in paroxysms of exceeding severity, ordinarily with intervals of some months between them. All these varieties, but particularly the last one, are not infrequently the outcome of the “insane temperament”. [15]

The relationship between alcoholism and psychiatric disease is complex. It is something of a chicken-and-egg situation, with one causing the other in both directions.

 

[6] Alcohol as a treatment

Alcohol is the most valuable cardiac stimulant we possess. It may be used in all febrile and exhausting disease as soon as the signs of failure of the heart present themselves, and it should be given at an early period of acute disorders to the old and feeble. Its stimulant effects on the digestive organs especially fit it for any case where there is feebleness of gastric functions. You must, however, bear in mind how generally it is used to excess by the poorer classes, and how liable the recommendation of the physician is to be quoted as a sanction for its abuse. Wine is the best form in which you can prescribe alcohol, and it ought to be given along with food. Spirits are employed when it is desired quickly to arouse the heart’s power, or where wine is unsuitable. [6]

You will likely have already noted that alcohol is given as a treatment in quite a few of the chapters in this book.

 

Next Week

We’ll spend one more week on addictions and take a look at how smoking is portrayed in the Sherlock Holmes stories.

 

Buying The Book

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Sherlock Holmes And The Adventure Of Masongill Hall

A story to accompany publication of The Medical Casebook Of Sherlock Holmes And Dr John Watson.

Sherlock Holmes has retired to his farm on the Sussex Downs, whilst Dr John Watson has become a GP in the Yorkshire Dales. Watson is struggling to deal with the first weeks of the COVID outbreak, yet Holmes discovers that an old enemy is about to carry out a terrible crime right under Watson’s nose. It is down to the heroic Watson to save the day.

Available from the Amazon Kindle Store.