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“He was a young man devoted to Vulcan, Bacchus and Venus” (Sir William Osler) I thought I should share some thoughts about alcohol, that colourless, odourless liquid that, when flavoured with various ketones and esters—becomes part of the national diet. My father was a master whisky-blender. I believe I was baptized with single malt (Bowmore, Islay). Dad’s expertise was smelling grain and malt liquor, and making wonderous combinations thereof (eg., Chivas Regal). But he could not drink the stuff. With unfettered access to spirits, he would have been pickled in short order. My first experience with booze was at age 18. I went to the “end-of-high-school-party,” armed with half a bottle of vodka. When my romantic interest fell into the arms of another, I challenged my virginal liver with every last drop. I remember stargazing that night, as the rain poured down. And cursing my Chemistry teacher, who later drove me home. I was ill. The next morning, my brother said, “Let’s go for a drive,” and I nearly died. When he rounded the first corner, I had acute vertigo. This was alcohol poisoning par excellence. I have never repeated that experience. My cerebellum and semi-circular canals made a full recovery. In Glasgow, being social meant going to the pub, a disorganized rowdy affair that left one short on memories but rich on experience. It would be remiss of me not to quote the bard himself, Robert Burns, who describes the perils of inebriation so well in his tale, “Tam O’Shanter”: “When chapman billies leave the street And drouthy neibours, neibours meet; As market days are wearing late, And folk begin to tak the gate, While we sit bousing at the nappy An’ getting fou and unco happy, We think na on the lang Scots miles, The mosses, waters, slaps and stiles, That lie between us and our hame, Where sits our sulky, sullen dame, Gathering her brows like a gathering storm, Nursing her wrath to keep it warm.” In translation: “When fellow workers head home At the end of the day Thirsty people come together At the local pub, and get plastered. Failing to bear in mind That our respective conjugal partner Might feel a bit left out” The tale goes on to report on Tam’s horseback ride home (drunk at the reins), past a haunted church, where the devil and some pretty scary folks are having a hell of a party: “Warlocks and witches in a dance: Nae cotillion brent new frae France, hornpipes, jigs, strathspeys and reels Put life and mettle in their heels” A bit like a heavy-metal-band-rave on steroids. Tam shouts out in support of a young female dancer, lightly clad: “Weel done, Cutty-sark! And in an instant, all was dark.” No, not a problem with the fuse box. Tam was definitely in the wrong place at the wrong time. He did well to outrun a marauding horde, crossing the Doon River bridge to reach safety. Alcohol poisoning, several levels worse than acute vertigo. We all have stories of the florid cirrhotic, the alcohol-related head trauma, an inconvenient hematemesis, withdrawal seizures and social calamity—all attributable to John Barleycorn. The illness that I remember best is—fortunately—not common. I was an undergraduate student. The unit registrar ushered our team into Roddy Flynn’s room. Roddy was 48, but he looked older. He had a ruddy complexion and a full crop of jet-black hair. He seemed peripherally gaunt, and a bit tremulous. Dr. Grant McMillan gently tapped the palm of his own hand with a tendon hammer. “Good morning, Roddy.” Roddy replied, in fearful tones, “Aw naw, don’t beat me up doc, I dinnae deserve this—not again.” We all looked at Dr. McMillan differently from then on. Roddy was clearly paranoid, and on further questioning exhibited both memory loss and confabulation (Wernicke-Korsakoff’s syndrome). The former is a neurological disease characterized by the triad of confusion, ataxia and ocular abnormalities (diplopia, nystagmus, and ophthalmoplegia). Korsakoff’s syndrome often follows, with short-term memory loss and sometimes the creation of imaginary events to fill the gaps (confabulation). Hmm, I’ve been known to do that quite often. WKS is the result of thiamine (vit B1) deficiency from chronic alcoholism or severe malnutrition. CT and MRI imaging may show shrinkage of the mammillary bodies—part of the limbic system— hence the memory loss. We exited quietly: Some of us were stirred, some were shaken. Once I was offered a “dram” after a Burns Night speech (Hyatt Hotel, Vancouver). I rarely drink Scotch: I have a collection of unopened, expensive malt whiskies I’ve inherited over the years. I made the mistake of accepting this dram, and I presume several more thereafter. It wasn’t long before my frontal lobes turned to jelly, and my disinhibition index hit double digits. The next day I paid a heavy price. “Under the weather” would be an understatement. I’ve never had so many people say “You look awful—are you feeling OK?” It’s one of the few times an insult, followed by a question, seems to convey compassion. Why do I raise this topic? One thing about the pandemic is undeniable: Liquor marts are doing brisk trade. Many of my overweight, diabetic, hypertensive, cardiomyopathic patients with atrial fibrillation are lubricating their isolation and boredom with generous amounts of this chemical fixative. If blood pressure is tough to treat, or atrial fibrillation is difficult to control, ask how much your patient is drinking. I try to point out that alcohol-dehydrogenase can cope with the first glass, but after that they are consuming a pickling agent as strong as formalin, damaging liver and pancreas, heart and brain. A labourer—burning 5,000 calories a day—might be lucky, but many of my retirees get most of their exercise surfing TV channels. And there are a LOT of calories in alcohol—almost twice as much as sugar—so it is a significant player in the obesity epidemic too. I quote the CHEP guidelines (Canadian Hypertension Education Program), that suggests no more than 14 alcoholic units for a man, nine for a woman, spread evenly over the week. That’s if you’re not on eight drugs for six diseases. Especially if one of these is an anticoagulant. I recognize the magnitude and consequence of the opioid crisis. I wonder how it would compare with the alcohol epidemic? References: 1. Tam O’Shanter, by Robert Burns (1791) https://en.wikipedia.org/wiki/Tam_o%27_Shanter_(poem) 2. Wernicke-Korsakoff Syndrome. https://rarediseases.org/rare-diseases/wernicke-korsakoff-syndrome 3. Wernicke, Carl. German psychiatrist and neuropathologist (1848-1905) 4. Korsakoff, Sergei. Russian neuropsychiatrist (1854-1900) 5. Barleycorn, John. Personification of barley products (whisky, beer); “A pleasant new ballad” (1624) - author unknown; “John Barleycorn”(1782) - by Robert Burns

Casebook of a Community Internist

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Hector Baillie

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