nature from that yielded by the fats and carbohydrates in their combustion. We may say that it is highly probable that such a difference does not exist, and assume with an equal degree of probability that the energy required for muscular work is drawn from the oxidation of alcohol as well as from the other food ingredients. As a matter of fact, when the total energy transformed with a diet containing no alcohol is compared with that transformed in a similar, parallel experiment in which 500 calories of the diet are furnished by alcohol, no noticeable difference appears. So far, then, as these experiments go, and with the quantities of alcohol used, no difference can be detected between the energy furnished the body by alcohol and that furnished by the ordinary nutrients of food, and, though failing to build tissue, alcohol can properly be classed as a source of energy to the body.

In thus furnishing fuel to the body it must spare either other food material or, what is still more important, body material from consumption. A diet deficient in energy results in an immediate draft upon the body material, chiefly fat, for the lacking energy. Alcohol added to such a diet invariably lessens the quantity of body material disintegrated. Similarly a diet just sufficient to maintain the body in equilibrium, when augmented by alcohol, results in a storage of fat in the body, or, if the diet is more than sufficient and fat has been stored, the amount stored will be increased. Marked instances of this protecting power of alcohol for fat are to be found in the published data of the Middletown experiments.

The contention has frequently been made that alcohol, even in moderate doses, influences the general metabolism of the body in such a way as either to increase or diminish the production of carbon dioxide and the consumption of oxygen. Widely varying results have been obtained on this point, though the best and most trustworthy work

shows that the variations in the carbon dioxide production and oxygen consumption are no larger than the variations appearing in a diet containing our ordinary nutrients.

Another and more serious question has been the effect of alcohol on proteid metabolism. Does the ingestion of a moderate amount of alcohol in twenty-four hours result in a more rapid disintegration of muscular tissue? This question naturally arose from the observation frequently made that in many instances the day after the ingestion of alcohol following an alcohol-free diet the nitrogen elimination in the urine is noticeably greater than before.* If we carefully examine all the experimental evidence it must be admitted that on the whole no tendency of alcohol to exert a direct poisonous action on proteid metabolism can be noted, for while the experiments of short duration in most instances show a somewhat greater elimination of nitrogen in the urine on the few days immediately following the ingestion of alcohol, the experiments of long duration invariably show that in a few days the normal excretion is soon re-established, and in many instances a gain of nitrogenous material to the body is clearly shown. The whole matter rests on the loss of a gram or two of nitrogen; and in interpreting the results of experiments of this nature, it is necessary to take into consideration several important points : (1) The elimination of nitrogen in the urine is not a measure of the tissue destroyed; (2) the diuretic effect† of alcohol might account for the slight increase in nitrogen elimination generally appearing for a few days after the ingestion of alcohol; (3) any marked change in diet, even when the nitrogen content is unaltered, is often accompanied by a marked disturbance of the nitrogenous equilibrium, and whatever fluctuations of the equilibrium are caused by alcohol in the diet are no greater than those

* Rosemann: Der Einfluss des Alkohols auf den Eiweissstoffwechsel, Arch f. d. ges. Physiol, 1901: Bd. 86, pp. 307-503; Rosenfeld: Der Einfluss des Alkohols auf den Organismus (1901) pp. 7–22.

Rintaro Mori: Arch. f. Hygiene, (1887) vii, 354.

caused by the ingestion of fat* under exactly similar conditions. The whole body seems to undergo a process of readjustment when a new diet is given, and in some instances the first few days are marked by a loss of nitrogen in the urine, as is the case when alcohol or fat are included in the diet, while in others the change is accompanied by a gain of nitrogen to the body.

We may safely say that the most accurate experiments give no positive proof or even valid ground for asserting that alcohol in moderate doses influences proteid metabolism any more than does fat. It cannot properly be designated as "proteid poison,"† but it can and frequently does protect body proteid from consumption.

While when used moderately alcohol may be said to "agree" with most people, its rapid absorption precluding difficulties of digestion; when used in excess, on the other hand, it produces, as do many of our common food materials, stomachic and other disturbances that are frequently of a serious nature. Unlike an inordinate fondness for sweets, nature does not rebel so vigorously against an excessive use of alcohol, and while opsomaniacs are relatively uncommon, dipsomaniacs are only too common. Even the coffee and tea habits cannot be compared in any sense with the strong habit so frequently acquired by users of alcohol. It is just this habit-forming property of alcohol leading to its consumption in excessive quantities, under which conditions the distinctly toxic properties of the compound are so manifest, that brings us to a halt in our estimate of the nutritive value of alcohol. The toxic properties of alcohol are not possessed by any other common food material, and consequently must be considered a drawback to its habitual use for nutriment in quantities large and small. Furthermore, if excessive doses are so disastrously toxic, may we not reasonably question the effect of moderate doses and

Kayser: v. Noordens Beiträge, H. 2, S. 1.

Miura: v. Noordens Beiträge, H. 1, S. 1.

suspect an insidious action, that may not be apparent in the necessarily short chemical, physical and physiological examination, of the subject, food and excreta, which is afforded by the usual experimental period. Experiments in the chemical or physiological laboratory, no matter how accurately made, can never of themselves furnish the data for determining satisfactorily the effects of the persistent use of moderate quantities of alcohol upon the general bodily and mental condition of man. It is to the pathologist and psychologist that we must look for answers to this question. While accurate and impartial observations on this point are rarely found, surely the work of Kraepelin,* Aschaffenburg and Hodge‡ is significant in its indications, and we must, at least, hold that alcohol has in many instances, even in moderate doses, a retarding action on many vital processes, and accordingly should be used for nutriment only with full cognizance of such action.

From a review of the work up to the present time, it can be seen that it would be manifestly unfair not to accord to alcohol a value as fuel and as a protector of body material — a value that may at times be of incalculable service to the physician, but would it not be equally manifestly unfair to deny that the latent toxic property of alcohol is such that in many, if not in the majority of cases in which it is used as a food, such use is irrational?

In health obviously the multitude of other materials whose nutritive value is beyond dispute renders the use of alcohol as a food entirely unnecessary. Pathological conditions in which nutriment from this source alone can be used are comparatively rare, though in many cases, as in acute infectious diseases, doubtless the ease of absorption and high calorific value more than counterbalance the toxic effects. Upon the intelligence of the physician, however, should rest the use of this compound as nutriment.

Psychologische Arbeiten, vols. 1 and 3.

+ Inaugural Dissertation Jena (1894).

Popular Science Monthly, 50, pp. 796-812 (1897).

ARTICLE XII.

THE BASIS FOR THE USE OF ALCOHOL IN THERAPEUTICS.

BY ARTHUR B. CUSHNY, M.D.

OF ANN ARBOR, MICH.

I HAVE, first of all, to thank you for the compliment you have paid me in inviting me to take part in this discussion. It is true that I might have selected another topic in preference to one which has been in the past and still is the cause of so much heart-burning as the therapeutic use of alcohol. But, at the same time, the position of the pharmacologists has been so much misunderstood, that I am very glad to have an opportunity to place it in its proper light. And as a pharmacologist I first must utter a protest against the prevalent idea that we base our statements wholly upon animal experiments. Any observation as to the action of a drug that is made in such a definite way that it can be verified by others is gratefully accepted by us, whether the subject of the experiment be a human being, sick or well, or one of the lower animals. But where a physician gives merely an impression, colored by his temperament or his hopes, we cannot take cognizance of it; and in this the pharmacologist differs in no whit from the medical profession, in which the danger of accepting subjective impressions as evidence is generally recognized.

In regard to the use of alcohol in therapeutics, perhaps more than in the case of most drugs, this tendency to substitute impressions for verifiable facts prevails, and in look