volatility, its avidity for water, its power to precipitate albuminous
substances from solution and to dissolve fats, and, finally, upon its
antiseptic properties.
Applied externally and permitted to evaporate, it produces a fall of
temperature and the sensation of cold; if evaporation be prevented, a
sensation of warmth is experienced, the skin reddens, and, if the
action be prolonged, desquamation results. The sensation produced when
diluted alcohol is applied to mucous surfaces is burning and stinging;
when concentrated, it may excite inflammation.
Dilute alcohol has been much employed as a surgical dressing for
wounds and ulcerated surfaces. Its value for this purpose depends on
its stimulating properties, by virtue of which it exerts a favorable
influence upon granulating surfaces; and on its antiseptic qualities,
which are, however, much inferior to those of salicylic and carbolic
acids among organic substances and to the chlorides among the
inorganic salts.
{582} 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
their {583} conflicting 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 Nothnagel[8] state 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.[9]
This view is also held by Parkes.[10]
[Footnote 8: Cited by Peeters, _L'Alcool, physiologie, pathologie,
médecine légale_, 1885.]
[Footnote 9: Henri 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.]
[Footnote 10: _Journal 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]
[Footnote 11: David 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.
{584} 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. Anstie[12] sought 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.
[Footnote 12: _Stimulants 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 functional {585} activity 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 no {586} longer 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]
[Footnote 13: This 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.”]
THE PATHOLOGICAL ACTION OF ALCOHOL.
I. Acute Alcoholism.
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 degree {587} unstable 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_. THE ORDINARY OR TYPICAL FORM.—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 baser
{588} passions 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.