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 corresponding
{589} to these stages.[14] Of 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.
[Footnote 14: These 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—
Methyl alcohol, CH_{3}OH.
Ethyl alcohol, C_{2}H_{5}OH.
Propyl alcohol, C_{3}H_{7}OH.
Butyl alcohol, C_{4}H_{9}OH.
Amyl alcohol, C_{5}H_{11}OH.
Richardson was the first to call attention to the differences in the
physiological and pathological action of the members of this series.
Other {590} observers, among whom may be named Dujardin-Beaumetz and
Andigie,[15] and Rabuteau,[16] have 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.[17] The
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.[18] So 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]
[Footnote 15: _Recherches expérimentales sur la Puissance toxique des
Alcools_, Paris, 1879.]
[Footnote 16: “Contributions à l'Étude des Effets physiologiques et
therapeutiques d'Alcool,” _Compt. rend. Société de Biologie_,
1870-71.]
[Footnote 17: “Methylic alcohol is the safest of the series of bodies
to which it belongs” (B. W. Richardson, _Lectures on Alcohol_).]
[Footnote 18: M. 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.]
[Footnote 19: Peeters, _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 escape {591} more 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,
{592} 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_. IRREGULAR FORMS OF ACUTE ALCOHOLISM.[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 often {593}
inarticulate, 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.
[Footnote 20: Ivresses 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
loss {594} of 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]
[Footnote 21: Consult also _Dict. 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 are {595} not 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.