The direct action of alcohol upon the mucosa of the digestive system depends upon the quantity ingested and degree of concentration. In moderate amounts and diluted to the extent of 50 per cent. or more, it produces a sensation of warmth in the tissues over which it passes. This sensation is due in part to the impression upon the nerve-endings, and in part to reflex hyperæmia, which is at once excited. In individuals unaccustomed to its use reflex contractions of the constrictor muscles of the pharynx, with gagging, are sometimes provoked. The secretion of saliva and of the gastric juice is increased, diluted alcohol being, in respect to its physiological effect in stimulating the buccal and gastric mucous glands, inferior to no other agent. This action is due as much to reflex as to local action, as has been shown experimentally by the application of a few drops of alcohol to the tongue of a dog with gastric fistula, increased secretion of gastric juice immediately resulting.
It is in consequence of this action that moderate doses of diluted alcohol exert a favorable influence upon the appetite and digestion. Increased amounts of food are well borne; fats especially are more tolerable and better digested; and a more energetic peristalsis favors the absorption of the food solutions. In those habituated to the use of alcohol these effects do not always follow; and if the amount be increased or the repetition become frequent, some part of the alcohol undergoes in the stomach, with the food, acid fermentation, and acid eructations or vomitings occur. With these phenomena is associated gastro-hepatic catarrh with its characteristic symptoms—loss of appetite, feeble digestion, diarrhœa alternating with constipation, sallowness, mental depression, and headache. In still greater amounts and little diluted, alcohol is capable of exciting acute gastritis or congestion and catarrhal inflammation of the liver.
When we come to study the action of alcohol upon the circulatory system, we find that in small doses it has little or no influence either upon the action of the heart or the condition of the vessels. In augmented amounts it increases the action of the heart both in force and frequency, and the arterial blood-pressure. After large doses these effects quickly pass away, and the circulation becomes depressed. The heart's action grows feebler, often slower, the pulse weaker; blood-pressure sinks and arterial tension is diminished. Its physiological action is that of a direct stimulant to the heart and the pneumogastric nerve; its toxic action, that of a depressant. Upon the vaso-motor system the action is from the first that of a depressant. Dilatation of capillary vessels and increased afflux of blood manifest themselves in the flushed face, brilliant eyes, and warmth of surface which are familiar phenomena. Frequent repetition tends to permanently impair the activity of the peripheral circulation. Hence the visible vascular twigs and rubicund nose that characterize the physiognomy of the habitual drinker.
This congestion no less affects the internal organs, setting up, by interference with their functions, chronic derangements of nutritive processes on the one hand, and on the other the liability to acute local diseases and complications.
The reactions which take place between the blood and alcohol remain, notwithstanding the energy devoted to their investigation, among the unsolved problems of physiological chemistry. It were a profitless task to here review the researches into this subject or to set forth theirconflicting results. It may be stated that conclusions based upon the reactions between blood drawn from the vessels and tested with alcohol in the laboratory are wholly inapplicable to the inquiry. While it is generally conceded that some part of the alcohol ingested undergoes decomposition within the organism, what the steps of the process are and what the products are have not yet been demonstrated. Rossbach and Nothnagel8state that it has not yet been possible to detect in the organism the products of the oxidation of alcohol—namely, aldehyde, acetic acid, and oxalic acid; nevertheless, acetic acid formed in the economy by the general combustion of alcohol may form acetates, which, undergoing decomposition, are transformed into carbonates and water, and are eliminated as such in the urine.9This view is also held by Parkes.10
8Cited by Peeters,L'Alcool, physiologie, pathologie, médecine légale, 1885.
9Henri Toffier found in the brain of a man who died of acute poisoning by alcohol not only alcohol, but also aldehyde:Considerations sur l'empoisonment aiqu par Alcohol, Paris, 1880.
10Journal of Practical Hygiene, 4th ed., Lond., 1873.
According to Peeters, the action of alcohol upon the blood may be summed up as follows: That portion of the ingested alcohol which undergoes decomposition takes from the blood some part of its oxygen for this purpose, with the result of a diminished amount of oxygen and an increase of carbon dioxide, the blood thus being made to resemble venous blood. A part of the oxygen destined for the oxidation of waste products being thus diverted, these substances are not completely transformed. In this respect also blood charged with alcohol resembles venous blood. Alcohol even when diluted is capable of retarding the combustion of oxidizable organic substances, and there is no reason to doubt that this agent has in the blood the same chemical properties that it elsewhere possesses.
The exhalation of some part of the alcohol circulating in the blood by the way of the pulmonary mucous membrane interferes with the elimination of carbon dioxide, with the result that the latter agent further tends to accumulate in the blood.11
11David Brodie,Medical Temperance Journal, October, 1880.
Alcohol must act, to some degree at least, directly upon the water of the blood and upon its albuminoid principles. The products of the reactions normally taking place within the corpuscles pass with greater difficulty into serum containing alcohol as the current of osmosis tends rather from the serum to the corpuscles. It is in accord with this fact that the corpuscles of alcoholized animals have been found relatively large.
The blood of individuals who have died in a state of alcoholic intoxication has been frequently found to contain an unusual amount of fatty matter in a fine state of subdivision.
Upon the respiration the influence of alcohol is twofold: it modifies the respiratory movements and the results of the respiratory processes. After moderate doses the movements are accelerated without disturbances of rhythm; after large doses the respiratory acts become embarrassed, feeble, irregular, finally wholly diaphragmatic.
Alcohol modifies the results of respiration in a constant manner and in all doses. This modification consists in a decrease in the amount of oxygen absorbed and carbon dioxide exhaled. This effect is usually more marked when alcohol is taken fasting than during digestion.
The influence of alcohol upon the renal secretion is that of a diuretic, but the fact must not be overlooked that this tendency is much increased by the large amount of water which alcoholic drinks necessarily contain. But that alcohol acts as a diuretic, even in small doses and altogether independently of the water with which it is taken, does not admit of doubt. The changes in the urine are qualitative as well as quantitative. The amount of urea, uric acid, and other solids is always notably diminished. The diminution of the amount of phosphoric acid is even greater than that of the nitrogenized substances, especially during the period of excitation.
The diuretic effect of alcohol is dependent upon its direct action on the parenchyma of the kidneys, the qualitative changes in the urine upon its influence on nutrition.
Upon the temperature of the body alcohol has a marked effect. The sensation of warmth experienced after moderate doses is chiefly subjective, and is accompanied by a very slight actual rise in temperature, amounting to some fraction of a degree Fahrenheit, and of but short duration. This rise is followed by a rapid fall, amounting to a degree or more below the norm. This effect is manifested within the course of an hour after the administration, and is of comparatively brief duration, being largely influenced by the condition of the individual at the time as regards mental or physical exercise, digestion, and the like. It is in part due to the increased loss of heat from the surface of the body, favored by more active cutaneous circulation, but chiefly to the action of alcohol in retarding oxidation and the activity of nutritive changes. Toxic doses are followed by marked fall of temperature. The influence of alcohol upon the temperature is more pronounced in febrile conditions than in health.
The influence of physiological doses of alcohol upon the nervous system is, among all its effects, the most marked and the most difficult to describe with exactitude. It is usual to regard this agent as a stimulant and to separate the period of its direct effects into two stages—that of excitement and that of depression. John Hunter defined stimuli as agents which increase some natural action or tendency, in contradistinction to irritants, which produce actions altogether abnormal. Anstie12sought to restrict the use of the term stimulant to agents which by their direct action tend to rectify some deficient or too redundant natural action or tendency. Without entering upon the discussion of the doctrine of stimulation, I may say that the views of Anstie have served a useful purpose in making clear some vexed questions. In accordance with these views, the physiological action of alcohol is followed neither by excitement nor by depression, and when its administration is followed by these conditions, its action is not truly physiological, but narcotic or toxic.
12Stimulants and Narcotics, Lond., 1864.
The effects of this agent upon the nervous system vary within very wide limits according to innumerable conditions which relate to the temperament, health, habits, occupation of the individual, season, climate, social circumstances, and the quantity, kind of alcoholic drink, and its mode of administration. Its first action in moderate doses and under circumstances free from complications is to increase the functionalactivity of the brain: the ideas flow more easily, the senses are more acute, speech is fluent, and movement active. These effects accompany the increase in the heart's action, the slight rise in temperature already described, and increased activity of the organism in general. They appear to be in part due to the direct action of the substance upon the cerebrum, and in part to increased activity of the circulation. The effect upon the nervous system has been compared by Nothnagel to the effect, in a higher sphere, of strong moral impulses. Without otherwise modifying existing traits of character, such impulses call them into action, and lead to the accomplishment of deeds quite impossible under ordinary circumstances. To a man worn out by some prolonged task which from sheer fatigue he despairs of finishing, let there be announced some joyful news; he at once feels refreshed, applies himself with renewed energy to his work, and perhaps finishes it with ease. In kind at least this is the effect also of alcohol.
But the limits of the physiological effects are easily transcended, and the manifestations then become those of its toxic influence, between the slightest grades of which and drunkenness the difference is one rather of degree than of kind. These effects must therefore be described under the heading Acute Alcoholism.
Passing to the influence of alcohol upon nutrition, we recognize two modes of action. Of these the first is direct and in part local, and results from the stimulation of the glandular apparatus of the mucous membrane of the mouth and stomach, from increased activity of the circulation, and from direct stimulation of the pneumogastric nerve. Hence increased secretion of the digestive juices, augmented appetite, more active peristalsis, and improved digestion, to which, indeed, the direct action of alcohol upon the cerebrum doubtless contributes. It is to these effects that the favorable influences of this agent in the extremes of life, when it is so well borne and so useful, must be largely attributed.
The second mode of action is indirect and general. It has been shown that alcohol diminishes the amount of carbon dioxide expired and of oxygen inspired, that it diminishes the quantity of urea excreted, and that it lowers the temperature of the body. It follows that normal oxidation goes on more slowly—that there is diminished tissue-change. Alcohol supports the body, not by nourishing it as a food, but by curtailing waste; it favors nutrition, not by augmenting the receipts, but by cutting down the expenses of the organism. But nutrition and waste are in health correlated and complementary. They are, in fact, essential and associated processes of life, of which one is not more necessary than the other to the maintenance of health. In various pathological states the arrest of waste is a cardinal indication, and for this purpose alcohol holds the first place. But in health this action itself is pathological, and the beginning of evil. The fat accumulation of the drunkard is due in part to the sugar and starchy matter taken in malt liquors, but much more to this control of waste, as is shown by the fact that spirit-drinkers who have sufficient food also often become fat. Alcoholic excesses tend not only to fat accumulation, but also to fatty degeneration of the tissues. The opinion that alcohol in any dose or under any circumstances is a food in the ordinary acceptation of the term is nolonger tenable. Chauffard has well said: “Not only is alcohol not an aliment; it is the very reverse. Not only does it not contribute to the nutrition of the body; it opposes it and destroys it little by little.”13
13This opinion is at variance with the views generally entertained by English and American writers upon materia medica. T. Lauder Brunton (Textbook of Pharmacology, Therapeutics, and Materia Medica, Am. ed., 1885) regards “all the evidence as pointing to the fact that alcohol is a food, and in certain circumstances, such as febrile conditions, may be a very useful food; but in health, when other kinds of food are abundant, it is unnecessary, and, as it interferes with oxidation, it is an inconvenient form of food.”
In accordance with the classification laid down at the beginning of this article, the term acute alcoholism is here used to denote the various forms of primary alcoholic intoxication in contradistinction to the conditions which are brought about by the gradual but long-continued action of the poison, and to the violent and sometimes abrupt outbreaks which are secondary to these conditions. From this point of view, which is at variance with the established usage of writers upon alcoholism, but which is here adopted in the hope that it will tend to simplify the treatment of a subject at present in much confusion, acute alcoholism includes all forms of drunkenness, from mere transient derangement of the normal functions of life, scarcely amounting to tipsiness, to profound intoxication. It includes also poisoning by lethal doses. Chronic alcoholism may be the outcome of frequent repetitions of acute alcoholism at short intervals, or it may result from the constant abuse of alcohol in doses so small that the evidences of its poisonous effects are at no time actively manifested. I hope to be able to show that the seemingly acute outbreaks, the symptoms of which chiefly relate to the nervous system, that occur after the condition of chronic alcoholism is fully established, are commonly preceded for a longer or shorter period by imperfectly developed symptoms of an analogous character, and that these outbreaks differ in essential particulars from acute alcoholism in all its forms.
That persons suffering from some degree of chronic alcoholism may, and as a matter of common occurrence do, after excessive doses suffer from acute alcoholism—in other words, get drunk—is too obvious to demand more than passing consideration at this point; but it is scarcely necessary to point out to those who are familiar with the life-history of such individuals that the time comes when no degree of excess will produce the ordinary manifestations of transient intoxication. It is then that phenomena of another and more serious kind are apt to occur. The difference is that between the reactions of normal or as yet quasi-normal tissues and alcohol on the one hand, and on the other the manifestations induced by the supersaturation of tissues previously alcoholized to the point of an acquired tolerance. This tolerance of the nervous system is in a high degree a pathological condition, and is therefore in an equally high degreeunstable and liable to be overthrown by accidents of various kinds as well as by extraordinary excess in alcohol.
The variety of forms and admixtures in which alcohol is taken is so great, and the susceptibility of individuals to its action so different, that it would be a hopeless task to attempt to describe the manifold phases of acute alcoholism. Unfortunately, most of them are too familiar. The following description embraces the more important phenomena, and is intended to serve as a type:
A. THEORDINARY ORTYPICALFORM.—The physiological effects of alcohol in moderate doses are followed by no reaction, but they are evanescent. When, however, the dose is repeated at short intervals and the effect is sustained, the condition by its continuance becomes pathological, and the subject enters upon the prodromic period of acute alcoholism. From this condition to that in which the poison manifests its distinctly toxic effects the transition is a speedy one. The face becomes flushed, the eyes brilliant; the heart's action increases in force and frequency; muscular force seems augmented; there is excitation of the mental processes; intelligence seems more active; ideas flow readily; preoccupation ceases; anxieties are forgotten. The future is full of hope, the past has lost its sorrows, its regrets. The powers of expression are brought into fullest play; conversation becomes animated, brilliant, often sparkling and keen. Reason is thrown aside, the judgment relaxed; vanity, pride, rashness, assert themselves. Emotions, sentiments, habitually repressed, are manifested without reserve, often with emphasis and insistance. Hence the proverb, In vino veritas.
Then speech degenerates into loquacity; improper confidences are made, indiscretions committed; the bent of disposition is made clear; he who is by nature sad grows sombre, melancholy; he who is irritable becomes cross and quarrelsome; the generous man grows lavish, and a good-natured fellow is everybody's friend. But this intensification of normal characteristics is by no means invariable. Not seldom do we see the timid man become in his cups violent and aggressive, the refined coarse, and the gay melancholy. The sensation of increase in muscular force manifests itself in unusual activity. Gesticulation is frequent, energetic, and apt; there are bodily restlessness and desire to move about. Shouts of laughter, bursts of song, are followed by a disposition to easily-provoked quarrels. At this stage there are evidences of some degree of cerebral congestion. The temples throb, the heart is full, and dizziness is felt. The skin is moist, the mouth pasty, thirst is experienced, and there is frequent desire to pass water. There yet remains some degree of self-control. The phenomena which characterize this condition are more or less transient, and if alcohol be now discontinued they speedily cease, commonly in sleep, sometimes without it, and are followed by sensations of weariness and fatigue, with headache, gastric disturbances, and temporary loss of appetite.
If, however, the influence of alcohol be pushed beyond this point, the manifestations of mere exaltation of function give place to grave perversion of the processes of life. A gradually increasing vertigo is associated with obscured intelligence, dulled imagination, blunted and confuted perception, disjointed ideation, and incoherent speech. The recollection grows indistinct, the will purposeless. Now the baserpassions are aroused; evil impulses and illusions of all kinds sway the drunken man. All control of conversation and action is lost. Reason is replaced by delirium, and he becomes a maniac, dangerous alike to himself and to others, liable upon some sudden impulse to commit the most atrocious crimes.
The countenance betrays the profound disturbance of the intellectual and moral nature: its expression is changed, its lines are blurred; the flush deepens, the veins are distended, the arteries pulsate visibly, the gaze is staring, the pupils contracted. The respiration, at first quickened, becomes irregular. The heart's action is rapid and bounding, and sometimes there is palpitation. Somnolence soon deepens into an invincible desire to sleep. At this point great muscular relaxation not infrequently occurs in connection with vomiting, profuse sweating, and dilatation of the pupils.
Muscular movements are irregular and uncertain, the gait vacillating and staggering; the movements of the superior extremities, wanting in precision, become trembling and awkward. At the same time speech becomes embarrassed. Articulation is difficult and imperfectly executed. At length standing becomes impossible; the drunkard, profoundly poisoned, sinks helplessly to the ground, and not infrequently the control of the sphincters is lost. The development of this condition is accompanied by a gradual perversion of general and special sensibility. Dull headache, ringing in the ears, phosphenes, and other disturbances of vision, hallucinations of taste and smell, are followed by abrogation of the special senses. Loss of cutaneous sensibility, beginning at the extremities, invades the whole body, and finally the subject sinks into more or less profound coma, from which it is no longer possible to arouse him. Muscular resolution is complete, sensation is lost; the face is now bloated, deeply flushed, sometimes livid, sometimes ashy pale; the pupils are dilated; the temperature below normal; the respiration stertorous and accompanied by abundant mucous râles. The pulse is feeble, fluttering, the surface covered with sweat, and involuntary evacuations take place.
VARIETIES.—Three varieties of acute alcoholism are recognized by Lentz—the expansive, the depressive, and the stupid. The first is characterized by gayety, self-satisfaction, and content. The drunkard, smiling and happy, is satisfied with the present and full of hope for the future. The second variety is characterized by sadness and melancholy. The drunkard becomes sombre and taciturn; if he talk at all, it is to bewail his misfortunes and to recount his mishaps. In the third variety the period of excitement is wanting and the drunkard passes rapidly into a condition of stupor.
Great as are the modifications of the course of acute alcoholism under different circumstances and in different individuals, it is evident, upon close investigation, that its phenomena—and especially those which relate to the nervous system—manifest themselves in a progressive series more or less constant in the majority of persons. This series includes three well-characterized periods: 1. The stage of functional exaltation of the nervous system; 2. The stage of functional perversion; 3. The stage of depression.
We may, then, recognize the degrees of acute alcoholism correspondingto these stages.14Of these, the first scarcely goes beyond the stage of excitement already described, and if the dose have been moderate or its repetitions not too long continued, the symptoms gradually subside, leaving perhaps no sequels beyond slight headache, tinnitus aurium, some degree of muscular relaxation, and mental depression.
14These stages correspond to the three degrees of alcoholic intoxication recognized and described by German writers as Rausch, Betrunkenheit, and Besoffenheit. To these may be added the prodromic period, designated as Weinwarme Zustand. These three degrees are known to the French as l'ivresse légère, l'ivresse grave, and l'ivresse suraiguë.
The second degree is characterized by partial abolition of intelligence, of general and special sensation, and of motor power. Hence incoherent speech, extravagant actions, blunted perceptions, hallucinations and delusions, inco-ordination of movements, a reeling gait, and not rarely vomiting and involuntary discharges of urine and feces. This degree of acute alcoholism usually ends in deep sleep with abundant perspiration, to which succeed great lassitude and depression, accompanied by much gastro-intestinal derangement, of which the symptoms are inability to take food, coated tongue, viscid mouth, foul breath, repeated vomiting, and occasionally diarrhœa. These sequels are less serious in those individuals accustomed to excesses than in others.
In the third degree the subject falls by gradual stages or abruptly into more or less profound coma. The abolition of intelligence, sensation, and motion is complete. The face is now swollen, livid, or pale, the pupils dilated, the respiration stertorous, the pulse feeble, often slow, sometimes imperceptible, the surface cool and often bathed in sweat. The man is dead drunk. The symptoms are now of the gravest kind. It is no uncommon occurrence for this condition to end in death.
Well characterized as these three degrees of alcoholic intoxication are, they are not, when occurring successively in the same individual, separated by abrupt lines of demarcation. On the contrary, the evolution of the symptoms is from the beginning to the close a gradual and progressive one.
While the scope of this article precludes extended discussion of the symptoms of acute alcoholism—which, indeed, present an almost endless variety in their intensity and combination—yet it seems necessary to the elucidation of the subject to point out some of the more prominent modifications due to variations in the conditions under which alcohol acts upon the organism.
First among these are differences in the nature and composition of the drink. Here we have to do not only with the well-known differences in alcoholic beverages, as spirits, wines, and malt liquors, and their quality and grades, but also with differences in the chemical nature of the alcohols themselves which enter into their composition. The principal of these alcohols are—
Richardson was the first to call attention to the differences in the physiological and pathological action of the members of this series. Otherobservers, among whom may be named Dujardin-Beaumetz and Andigie,15and Rabuteau,16have also investigated the subject. The researches of these observers have established the fact that the effects of the different alcohols in depressing the temperature of the body and in paralyzing sensation and motion are exactly the same, but that their narcotic influence upon the nervous system increases, dose for dose, in proportion to the amount of carbon which they contain. Ethyl alcohol is, with the exception of methyl alcohol or wood-spirit, the least rich in carbon and the least dangerous to health.17The increased consumption of alcohol, both as a beverage and in the arts, the demand for cheap, coarse spirits producing their primary narcotic effects with promptness, and the cupidity of manufacturers, have led to the almost universal adulteration of the liquors of commerce with the more dangerous alcohols.18So extensive has this substitution of the high-carbon alcohols for ethyl or ordinary spirit of wine become that it has been suggested that alcoholism should be divided into ethylism, amylism, propylism, and butylism—not so much for clinical reasons as to direct attention to the composition of alcoholic drinks and to their deleterious properties.19
15Recherches expérimentales sur la Puissance toxique des Alcools, Paris, 1879.
16“Contributions à l'Étude des Effets physiologiques et therapeutiques d'Alcool,”Compt. rend. Société de Biologie, 1870-71.
17“Methylic alcohol is the safest of the series of bodies to which it belongs” (B. W. Richardson,Lectures on Alcohol).
18M. Girard, chief of the municipal laboratory in Paris, has recently called attention to the enormous diminution in the production of alcohol by the natural method—that is to say, by the distillation of wine. The falling off he ascribes to the ravages of the phylloxera. This loss is made up by the substitution of spirits obtained by the distillation of various fermented grains, potatoes, beets, molasses, etc. To give some idea of the extent to which the alcohols of industry at present replace the alcohols of wine, he cites the following figures: From 1840 to 1850 the mean annual production of alcohol in France was 891,500 hectoliters, of which the alcohols of wine amounted to 715,000 hectoliters. In 1883 the product reached 1,997,280 hectoliters, of which alcohols obtained by the distillation of wine amounted to only 14,678 hectoliters.
19Peeters,L'Alcool, 1885.
The effects of propyl, butyl, and amyl alcohols upon the nervous system are not only more marked than those of ethyl alcohol, but they are more rapid. The stage of excitement is speedily induced, and its manifestations are intense. Hence the preference often manifested by drunkards for cheap, coarse spirits. On the other hand, the stage of depression quickly follows, and is itself of relatively shorter duration than that induced by ethyl alcohol, probably for the reason that the amount required to bring it about is smaller. Muscular resolution soon becomes general and complete; insensibility speedily succeeds; the fall of temperature is rapid; vomiting, occasionally absent in the intoxication produced by ethyl alcohol, is the rule, and is frequently repeated. Muscular tremor—and especially is this true of amyl alcohol—comes on earlier, is more general and more marked, and lasts longer than that which occurs in consequence of excess in ethyl alcohol. Richardson states that the complex alcohols are more slowly eliminated than ethyl alcohol, but the French observers are of a different opinion.
But these differences in action are probably rather differences in degree than in kind. Peeters says: “Ethyl alcohol is less dangerous than the more complex members of the series. It is less irritating, less charged with carbon, its specific gravity is less, its fumes are less dense and escapemore readily from the economy; its action ought to be less profound, less prolonged, than that of butyl, propyl, and amyl alcohol, but it is of the same nature. It is not qualitatively but quantitatively different. I suspect that the effects of liquors containing ethyl alcohol are, as a rule, less decidedly injurious, by reason of the more favorable surroundings of those who can afford to use them.”
The three principal groups of the alcoholic drinks of commerce produce, independently of the properties of the different kinds of alcohol which they contain, forms of acute alcoholism which differ in important respects.
The intoxication induced by the exclusive use of malt liquors is dull and heavy, slow in coming on, and of long duration. The stage of excitement is relatively brief, not often characterized by gayety, often brutal; drowsiness soon supervenes and deepens slowly into unconsciousness. The after-effects are disagreeable and prolonged. The enormous quantity of fluid and the large amount of malt extractives cause gastro-hepatic derangements of a more or less distressing kind. To the hops must be ascribed the prolonged dulness which is so characteristic of the after-effects of beers and ales. The influence of the various substances used in the adulteration of beers without doubt modifies the symptoms of the alcoholism which these beverages cause when impure. These substances consist of glucose, various vegetable bitters, and salt—articles not necessarily hurtful in small amounts, but capable of exerting deleterious action when taken in excess and in connection with the normal ingredients of beer.
The intoxication produced by pure wines is, as a rule, characterized by a bodily and mental activity strongly in contrast with the drunkenness produced by malt liquors. The drunkard is usually gay and vivacious—at all events, lightly merry or not hopelessly despondent. His mood is variable, changing from grave to gay. The first stage is prolonged, and the manifestations of the later stages less grave, nor are the sequels apt to be so severe. The action is that of ethyl alcohol and certain ethereal substances, the latter being present, however, only in minute amounts. The rapidity of the effects depends upon the proportion of alcohol which the wine contains, which varies from about 7 per cent. in the clarets to 15, to 18, or even to 20 per cent. in port and madeira. The sparkling wines, moselle and champagne, produce more transient effects than the still wines—a fact probably to be explained by their greater and more prompt diuretic action.
The foregoing remarks apply only to pure wines. The intoxication which follows the use of artificial compounds sold in all parts of the world as wines betrays in its course and symptoms the high percentage and toxic characters of the mixed alcohols which form their essential ingredients.
The intoxication which follows excesses in the various spirits of commerce presents no special characters. Its symptoms are determined to a considerable extent by the relative purity—that is, freedom from admixture with the various complex alcohols—of the liquor by which it has been produced. Potato spirit causes drunkenness which is profound, overwhelming, and preceded by a brief period only of excitement.
Even more important than the kind of liquor is its quantity. Here,however, it is impossible to formulate precise statements. A few glasses of wine will produce effects in some persons more decided than much strong spirits in others. Those conditions which favor the absorption of alcohol hasten the production and augment the intensity of alcoholism; and the contrary is true. Thus, alcohol taken while fasting does much more harm than the same amount taken with a meal. Intense excitement, anger, mortification, or other violent emotion is said by Lentz to increase the effects of alcohol. Sudden transition from a warm to a cold atmosphere intensifies the action. That this effect of cold is due to suppression of perspiration, and the consequent interference with one of the elements of elimination, is much less likely than that it is due to the further depressing influence of cold upon the nervous system, already depressed by the alcohol imbibed. Occupation has in an indirect way much to do with the facility with which alcohol is borne. Hard work, requiring great and continuous muscular effort, especially in the open air, diminishes the liability to acute alcoholism, while sedentary occupations and confinement strongly predispose to it. These well-recognized facts are to be accounted for by the influence of different occupations and modes of life upon the elimination of the poison. Persons who are debilitated by chronic disease or are convalescent from acute maladies, and the otherwise feeble and anæmic, are peculiarly obnoxious to the action of alcohol. Previous custom and hereditary peculiarities of organization exert an influence upon the liability of individuals to acute alcoholism, and upon its nature when induced.
Persons of an impressible nervous organization are peculiarly prone to the evil effects of drink. With such persons slight excess is often followed by serious consequences; the intellectual disturbance is early developed and out of proportion to the derangements of motility and sensation. The effects of alcohol are manifested more promptly and more intensely in children and women than in men or in the aged. Drunkenness is induced more rapidly and with smaller quantities of alcohol in summer than in winter, in warm than in cold countries.
B. IRREGULARFORMS OFACUTEALCOHOLISM.20—1.The Maniacal Form.—The outbreak is usually sudden, sometimes occurring after the ingestion of comparatively small quantities of alcohol; at others after excesses which in a certain proportion of the cases have already ceased. The transition from a condition apparently normal, or marked at most by mental concentration, restlessness, and some degree of irritability, to furious mania is sometimes almost instantaneous, and the subsidence of the latter no less swift. More commonly there are prodromic symptoms, among which are general malaise, præcordial distress, palpitations, flushing of the face, vertigo, tinnitus aurium, phosphenes, and dull, throbbing headache. The attack is characterized by maniacal excitement, usually of a furious kind. The restlessness is, however, far from being aimless and purposeless. On the contrary, impelled by the wildest passions, transported with rage, the patient seeks the destruction of life and property, and wreaks his fury alike upon animate and inanimate objects. So great is his strength for the time being that several strong men may be scarcely able to restrain him. He pours forth a torrent of commingled threats and curses, in which may be heard unintelligible, and ofteninarticulate, sounds. He is beside himself, yet, so far as can be learned, there are neither hallucinations nor delusions by which his fury can be explained. In this respect the condition is wholly unlike that form of alcoholic mania in which the actions are explained by the imaginary surroundings and circumstances of the patient. In the maniacal form of acute alcoholism the most trifling incident, a word, a look, are sufficient to produce a tempest of rage that may end in scenes of violence. Nevertheless, the patient yet retains for a time some notion of his surroundings. At length, however, he falls into a state of complete unconsciousness, and the delirium is like that of fever, of the delusions of which no recollection afterward remains. This form of acute alcoholism is almost invariably associated with the symptoms of a high degree of cerebral hyperæmia. The hands are hot, the eyes injected, the pupils dilated or contracted, the expression eager. There are abundant secretion of saliva, frequent and irregular respiration, a rapid pulse—often exceeding 100—throbbing arteries, distended veins, and a hot skin, often bathed with sweat. The urine is scanty and constipation usual. There is, as a rule, increased sensibility to light and sound. The attack is liable to come to a tragic close in murder or suicide.
20Ivresses anormales ou pathologiques of the French writers.
The termination of the paroxysm is as abrupt as its onset. Some abatement of its violence is quickly followed by signs of mental and bodily exhaustion; this deepens into profound sleep, which often lasts from twelve to twenty-four hours, and from which the patient awakes clear, tranquil, and as if nothing had happened, or dimly recollecting the occurrences that have passed as a hideous dream. In a small proportion of the cases the sleep deepens into coma which ends in death.
2.The Convulsive Form.—The analogy to the form just described is very close. Here, however, the morbid manifestations directly relate to the muscular system. The attack is commonly sudden, often abrupt. When prodromes occur, they are such as have been described as preceding the maniacal form—mental irritability, headache, præcordial distress, etc. The attack is thus described by Lentz: “The phenomena consist not in ordinary convulsions, but in convulsiform movements of remarkable disorder, only to be compared with the extraordinary convulsive movements of grave hysteria. We have happened to see several cases during the attack. These patients threw themselves to the ground, giving themselves up to the most irregular and disorderly contortions, rolling from side to side, throwing the body into the air, striking out with the legs and arms, kicking at random, biting at persons and things—now knocking the head against the floor, again rising for a moment, only to fall back and commence again the same contortions. Their movements are energetic and violent. There are madmen whom it is dangerous to approach by reason of the violence of their movements, but they are certainly much less dangerous than those suffering from the maniacal form of acute alcoholism, for their morbid motility has no tendency to take the shape of co-ordinated actions. It is movement wasted in pure loss. Their muscular energy is excessive; it is difficult to restrain them. To resume: the peculiarity of these movements is this, that they are not intentional, but that they are rather purely convulsiform, automatic.
“Another phenomenon of this form, one of its characteristic symptoms, is the state of intellectual enfeeblement which accompanies it. The lossof consciousness is complete, and were it not for the movement produced by the convulsions the patient would be plunged into a condition of profound coma. He has not the least knowledge of himself; not even delirium denotes intellectual activity; only an occasional harsh cry or inarticulate sound indicates the existence of mind.”
The other symptoms differ but little from the maniacal form. The duration of the attack varies from a few hours to half a day; its termination is usually abrupt, the patient falling into a condition of extreme exhaustion with stupor, or into a deep and prolonged sleep, from which he awakens without the slightest recollection of the attack through which he has passed.21
21Consult alsoDict. des Sciences méd., t. xxvi.
3.Acute Alcoholism, in Persons of Unsound Mind.—The insane, imbeciles, epileptics, and persons suffering from nervous diseases are, as a rule, abnormally susceptible to the action of alcohol, and present more or less striking peculiarities in the symptoms which it causes. Brief notice of certain of these peculiarities is in accordance with the scope and plan of this article.
In general paralysis propensity to alcoholic excesses is not rarely an early symptom. The subject is very susceptible to the action of alcohol, and under its influence rapidly passes into a state of intense excitement, characterized by incoherence, delirium, excessive restlessness, and unwillingness to seek repose until exhaustion is complete. It is under the influence of this easily-provoked alcoholic excitement that the vagabondage, quarrels, thefts, robberies, incendiarisms, and other grave crimes observed during the first stage of this form of insanity are often committed.
Imbeciles and idiots are likewise quickly, and often intensely, excited by alcohol. They are then apt to be quarrelsome, perverse, and ungovernable, defiant of authority, and capable of shocking crimes, often evincing latent vicious tendencies previously wholly unsuspected.
Epileptics are easily affected by alcohol, and usually violent in the stage of excitement; not rarely this period terminates in a true epileptic seizure.
The drunkenness of the dipsomaniac is characterized by a prolonged, uninterrupted stage of excitement without the stage of depression. Such individuals are capable of consuming in their periodical excesses large amounts of drink without the evolution of the ordinary successive phenomena of acute alcoholism.
Persons of unsound mind are, as a rule, so susceptible to the influence of alcohol, and suffer so promptly and intensely from its primary effects, that they are rarely able or permitted to consume a sufficient quantity to bring about a comatose state.
The irregular forms of acute alcoholism are only to be explained by the inherited or acquired constitutional peculiarities of individuals. To attempt to explain them in any case by the quality of the alcohol by which they are induced meets with the difficulty indicated in the fact that they are isolated and comparatively rare, even where the coarser spirits are habitually consumed. They occur in individuals who habitually commit excesses, but they cannot be viewed as manifestations of chronic alcoholism, for the reason that they also occasionally occur in those who arenot habitual drinkers, and even in persons who have not for a long time previously tasted strong drink. Furthermore, as has been pointed out, they are not only occasionally, but indeed even as a rule, induced by relatively small amounts of alcohol. They are then the manifestations of idiosyncrasy. One of the striking peculiarities of this peculiar bodily organization is this very susceptibility to the action of alcohol in doses smaller than are taken with impunity by ordinary individuals. It is also characterized by a special tendency to delirium in febrile states, to hallucinations, to disturbances from trifling changes in climate, food, or manner of life, to irritability of the nervous system, and in particular of the vaso-motor system, and by a tendency to convulsions. With these tendencies is associated an unstable mental and moral character. Such persons are liable to headaches, vertigo, and epistaxis—signs of cerebral hyperæmia, which is easily induced—and their family histories indicate strong hereditary tendencies to neurotic disorders, and not rarely addiction to alcohol on the part of one or several ancestors.
But this idiosyncrasy is by no means always an inherited one. It is acquired as one of the results of profound disturbance of the nervous system, such as is produced by moral causes, by temporary or recurrent insanity, by wounds and injuries of the head, by the infectious diseases, especially syphilis, enteric and typhus fever, and small-pox, and by inflammations of the meninges.
What may be the precise mode of action of alcohol in the production of its acute effects yet remains a matter of conjecture. It cannot be doubted that its primary and direct action is upon the nervous system, and that the circulation is secondarily but rapidly implicated. But it is quite impossible to say, in the present state of knowledge, what this action is. It has been suggested that certain chemical modifications of alcohol in the blood, or of the blood itself in the presence of alcohol, cause these phenomena; that aldehyde is the active agent in their production; that the chemical changes by which alcohol is transformed into aldehydes, acetic acid, and finally into carbon dioxide, deprive the blood of the oxygen necessary for the proper performance of the functions of the nervous system. Unfortunately for these views, neither the presence of aldehydes in the blood in acute alcoholism, nor these transformations themselves, have yet been demonstrated, and a high degree of deoxygenation of the blood is frequently observed in asphyxia, the inhalation of nitrous oxide, etc., without the train of symptoms characteristic of the condition now under consideration.
It is more than probable that varying conditions of the cerebral circulation, secondary in themselves, have much to do in the causation of certain symptoms. The experimental investigations of Bernard and others have established the fact that during the period of excitement there is actual congestion of the meninges. This condition is transient, and reproduced after each repetition of the dose. After a time, or if the dose at first be excessive, the congestion is succeeded by anæmia.
PATHOLOGICALANATOMY.—Upon the examination of the bodies of persons who have died by accident while drunk or in consequence of drunkenness itself, deep congestion of the cerebral meninges, and especially of the pia, has been almost constantly observed. In the pia effusions of blood are occasionally encountered. The condition of the cerebralsubstance is not always the same. It is in a majority of the cases more or less deeply congested, yet it presents in other instances no appreciable departure from the normal state, and in a smaller number still there is actual anæmia.
The sinuses and choroid plexuses are distended with dark blood; the cerebro-spinal fluid is increased, and often tinged with blood; the ventricles are distended with fluid, which not rarely has an alcoholic odor. Occasionally the ventricles contain blood, and hemorrhage into the substance of the brain has been observed.
The condition of the elementary nervous tissues after death from acute alcoholism is not yet known.
The lungs are deeply congested, with small extravasations of blood into their substance, and often œdematous. Congestion of the liver, spleen, and kidneys in varying degrees of intensity is also seen. The pancreas is usually deeply injected, occasionally the seat of large extravasations of blood. The mucous membrane of the stomach is invariably deeply injected when the alcohol has been introduced into the organism in the ordinary manner. The observation of Caspar that post-mortem decomposition takes place with diminished rapidity has been denied by Lancereaux and others.
Other post-mortem conditions appear to be neither constant nor characteristic. The stomach usually contains partially digested food and alcohol. Lallemand, Perrin, and Du Roy observed, both during life and after death, in the blood of animals subjected to experiments, great numbers of minute glistening points, which upon microscopic examination proved to be fat-globules. The same condition has been observed in man, not only when death has taken place owing to acute alcoholism, but also when it has occurred during the digestion of a hearty meal without alcohol. The blood itself is often fluid and dark-colored; the heart sometimes empty, sometimes containing a few soft clots. Tardieu22states that in sudden death during drunkenness pulmonary apoplexy and meningeal apoplexy, if not constant lesions, are at least extremely frequent, and almost characteristic. Baer, on the other hand, denies the occurrence of specific or characteristic lesions.
22“Observationes médicales sur l'Etát d'Ivresse,”Annales d'Hygiene publique et de Médecine légale, tome xl.
C. ACUTEPOISONING BYALCOHOL INLETHALDOSES.—The symptoms are much modified when overwhelming doses of strong alcohol are introduced into the organism at once or in the course of a short time. Here alcohol produces death as an acute poison. The cases may be arranged in two groups:
1.Corrosive Poisoning.—These cases are very rare. They are caused only by undiluted alcohol, and depend upon the action of this agent in coagulating albumen and disorganizing the tissues with which it comes in contact by its affinity for the water which they contain. Absolute alcohol is a powerful corrosive poison. It produces intense phlegmonous inflammation of the œsophagus and stomach, with erosion of the mucous membrane, accompanied by vomiting, diarrhœa with bloody stools, prostration, and stupor. Death occurs by heart-failure. Among the direct effects of large doses somewhat less concentrated are acute and subacute gastritis with characteristic symptoms.