Friday, March 26, 2010

Aphorisms About Alcohol

Alcoholism is a trap for the unwary physician. I do not mean overt, flagrant, persistent, disgracing drunkenness. It is covert, concealed alcohol addiction which corrupts diagnosis, wasting time, and money, while creating the risks of inappropriate or unnecessary investigation and treatment.
So I offer these aphorisms: if you think I am cynical, take it as a confession that I missed occult alcoholism too often.

1. Alcohol drives out honesty.

As a newly appointed physician a respected senior colleague advised me thus.
"Don't waste your time asking people about their drinking habits: you can't believe a word they say."
I have many times been made aware of the truth he spoke, and of the shameless, facile lying which alcoholics use, attempting to deceive themselves and the physician.
A middle-aged businessman was in hospital with severe alcoholic hepatitis. He recovered and returned to the clinic after 6 weeks for review. He assured me he had heeded my warnings: "Not a drop has passed my lips since I left hospital". His speech was slurred, he was unsteady on his feet; his blood alcohol was 85 mg%; and it was 1015 on Monday morning.

2. Husbands deny their wives' drinking; wives declare their husbands' drinking.

A 32 years old woman had blackouts at home, then was brought home by a friend after falling in a supermarket. The friend told the doctor she was drunk, her husband denied this. Her sister came with her to a second clinic visit, to tell me privately she was drinking at least a bottle of vodka a day. Still husband and wife denied an alcohol problem. They told me she had fits as a child; the blackouts were epileptic. Eventually she fell again and was brought to casualty, obviously drunk - her blood alcohol was more than 300mg%.
On a number of occasions a wife became restless as her husband assured me his drinking was modest - a glass of wine with dinner, perhaps, sometimes a nightcap. Then she would interrupt forcefully, something like this.
"That's not right; you tell the doctor the truth. It's a bottle of wine every evening, and a lot of gin. And he's in the pub every lunchtime. He buys the drink - but I put out the bottles for the dustman."

3. Wives divorce alcoholic husbands; husbands shelter alcoholic wives.

Alcohol unmasks crude, immature sexual characteristics: men tend to aggression and violence, women to provocation and flirting. Women will put up with violence to themselves, sometimes to a surprising degree, but violence to their children they will not tolerate. Conversely the behaviour of a drunken wife is likely to engender primitive male responses of protection and possession; and an alcoholic wife shames a man, hinting he is inadequate.

4. Suspect alcohol if something is hard to explain.

An elderly lady had a stroke, with left sided weakness. After 3 weeks her strength had returned but she was still unsteady and couldn't walk. She lived with two sisters, who visited most days, bringing a large plastic lemonade bottle. A student nurse became suspicious, checked the bottle and found it contained vodka. That patient was drinking vodka like lemonade, in hospital, and I had failed to spot it.

5. Alcoholism may explain social failure.

Failure to be promoted, unexpected bankruptcy, divorce not for adultery, loss of the driving licence: all such should arouse suspicion. Of course these personal failures have various causes; alcoholism is likely to be denied or concealed.

6. Alcohol preys on success and wealth.

George Best is an obvious example. 25 years ago in England, compared to the general population, doctors, lawyers and army officers had 3 times the risk of alcoholic cirrhosis; for barristers, judges and journalists the risk was increased 9 times; for company directors it was into double figures. For the modern profession of celebrity the risk probably goes higher still.

Finally - look critically at 'routine' blood tests. Three values may suggest alcoholism, singly or together. They are useful only if abnormal: normal values do not rule out alcoholism.

Automatic blood counters calculate the average size of the red cells in the blood - the mean corpuscular volume, MCV. A moderately increased MCV, say 100-105, suggests alcoholism.
The cause of this is interesting. The normal red blood cell is a disc with two concave faces. Alcohol causes some red cells to develop with four concavities, creating cells shaped as a regular tetrahedron. From above these cells appear triangular, and are called triangulocytes. They are bigger than normal red cells, so increasing the MCV.

Other markers of alcohol include an increased plasma value for the enzyme gamma-glutamyl transpeptidase - gamma-GT. This enzyme is important in the metabolism of folic acid.
Another marker is a low value for the blood urea. This can be attributed to poor protein nutrition: alcohol is rich in energy, and is expensive. It may also reflect chronic liver injury and reduced urea synthesis.

The old truisms are true. Alcohol is a good friend, but an evil master. It increases the desire, but impairs the performance. Enjoy a drink with friends, but shun the disgrace of drunkenness.
Alcohol in strict moderation is healthy, especially red wine, giving some protection against coronary thrombosis, for example. I advised one glass of red wine every evening for my coronary patients; that was my only prescription where compliance approached 100%.

And there is the old Arabic proverb, taught me by an eminent Egyptian scholar:
wa qalil min al khamr yasla' al ma'ida
[and a little alcohol awakens the stomach.
Or, maybe:
and a little wine puts fire in the belly.]


Anonymous said...

A very wise article AEP. I have been through some of the experiences you mention (I was the husband refusing to acknowledge my wife's problem) and you have described our behaviours exactly.

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