III.—Alcohols.
1. ETHYLIC ALCOHOL.
§ 158. The chemical properties of ordinary alcohol are fully described, with the appropriate tests, in “Foods,” pp. 369-384, and the reader is also referred to the same volume for the composition and strength of the various alcoholic drinks.
Statistics.—If we were to include in one list the deaths indirectly due to chronic, as well as acute poisoning by alcohol, it would stand first of all poisons in order of frequency, but the taking of doses so large as to cause death in a few hours is rare. The deaths from alcohol are included by the English registrar-general under two heads, viz., those returned as dying from delirium tremens, and those certified as due directly to intemperance.
During the twenty-five years, from 1868 to 1892, 30,219 deaths have been registered as due to intemperance, which gives an average of 1209 per year. The rate per million has varied during the period from 29 to 71; and the figures taken as a whole show that deaths from intemperance appear to be increasing; the increase may be only apparent, not real, for it is a significant circumstance that deaths registered under liver diseases show a corresponding decrease; it is, therefore, not unlikely that deaths which formerly would be ascribed to liver disease, are more often now stated to be the effects of intemperance.
Deaths directly due to large doses of alcohol are not uncommon; during the ten years ending 1892, 105 deaths (81 males and 24 females) were ascribed under the head of “accident or negligence” directly to alcohol.
CHART SHEWING DEATHS PER MILLION PERSONS LIVING, FROM INTEMPERANCE & FROM LIVER DISEASES.
| THE MEDICAL “OFFICERS OF HEALTH” CHART. | ENT. AT STA. HALL. |
| Notes. | |||
| Intemperance |  | ||
| Liver disease |  | ||
| The Scale for Intemperance is as printed. | |||
| That for Liver diseases is 10 times larger. | |||
§ 159. Criminal or Accidental Alcoholic Poisoning.—Suicide by alcohol, in the common acceptation of the term, is rare, and murder still rarer, though not unknown. In the ten years ending 1892, only three deaths from alcohol (1 male and 2 females) are recorded as suicidal. Perhaps the most common cause of fatal acute poisoning by alcohol is either a foolish wager, by which a man bets that he can drink so many glasses of spirits without bad effect; or else the drugging of a person already drunk by his companions in a sportive spirit.
§ 160. Fatal Dose.—It is difficult to say what would be likely to prove a lethal dose of alcohol, for a great deal depends, without doubt, on the dilution of the spirit, since the mere local action of strong alcohol on the mucous membranes of the stomach, &c., is severe (one may almost say corrosive), and would aid the more remote effects. In Maschka’s case,[149] a boy of nine years and a girl of five, died from about two and a half ounces of spirit of 67 per cent. strength, or 48·2 c.c. (1·7 oz.) of absolute alcohol.
[149] Recorded by Maschka (Gutachten der Prager Facultät, iv. 239; see also Maschka’s Handbuch der gericht. Medicin, Band. ii. p. 384). The following is a brief summary:—Franz. Z., nine years old, and Caroline Z., eight years old, were poisoned by their stepfather with spirit of 67 per cent. strength taken in small quantities by each—at first by persuasion, and the remainder administered by force. About one-eighth of a pint is said to have been given to each child. Both vomited somewhat, then lying down, stertorous breathing at once came on, and they quickly died. The autopsy, three days after death, showed dilatation of the pupils; rigor mortis present in the boy, not in the girl; and the membranes of the brain filled with dark fluid blood. The smell of alcohol was perceptible on opening the chest; the mucous membrane of the bronchial tubes and gullet was normal, both lungs œdematous, the fine tubes gorged with a bloody frothy fluid, and the mucous membrane of the whole intestinal canal was reddened. The stomach was not, unfortunately, examined, being reserved for chemical analysis. The heart was healthy; the pericardium contained some straw-coloured fluid. Chemical analysis gave an entirely negative result, which must have been from insufficient material having been submitted to the analyst, for I cannot see how the vapours of alcohol could have been detected by the smell, and yet have evaded chemical processes.
In a case related by Taylor, a child, seven years old, died from some quantity of brandy, probably about 113·4 c.c. (4 ozs.), which would be equal to at least 56·7 c.c. (2 ozs.) of absolute alcohol. From other cases in which the quantity of absolute alcohol can be, with some approximation to the truth, valued, it is evident that, for any child below ten or twelve, quantities of from 28·3 to 56·6 c.c. (1-2 ozs.) of absolute alcohol contained in brandy, gin, &c., would be a highly dangerous and probably fatal dose; while the toxic dose for adults is somewhere between 71·8-141·7 c.c. (2·5-5 ozs.).
§ 161. Symptoms.—In the cases of rapid poisoning by a large dose of alcohol, which alone concern us, the preliminary, and too familiar excitement of the drunkard, may be hardly observable; but the second stage, that of depression, rapidly sets in; the unhappy victim sinks down to the ground helpless, the face pale, the eyes injected and staring, the pupils dilated, acting sluggishly to light, and the skin remarkably cold. Fräntzel[150] found, in a case in which the patient survived, a temperature of only 24·6° in the rectum, and in that of another person who died, a temperature of 23·8°. The mucous membranes are of a peculiar dusky blue; the pulse, which at first is quick, soon becomes slow and small; the respiration is also slowed, intermittent, and stertorous; there is complete loss of consciousness and motion; the breath smells strongly of the alcoholic drink, and if the coma continues there may be vomiting and involuntary passing of excreta. Death ultimately occurs through paralysis of the respiratory centres. Convulsions in adults are rare, in children frequent. Death has more than once been immediately caused, not by the poison, but by accidents dependent upon loss of consciousness. Thus food has been sucked into the air-tubes, or the person has fallen, so that the face was buried in water, ordure, or mud; here suffocation has been induced by mechanical causes.
[150] Temperaturerniedrigung durch Alcoholintoxication, Charité Annalen, i. 371.
A remarkable course not known with any other narcotic is that in which the symptoms remit, the person wakes up, as it were, moves about and does one or more rational acts, and then suddenly dies. In this case also, the death is not directly due to alcohol, but indirectly—the alcohol having developed œdema, pneumonia, or other affection of the lungs, which causes the sudden termination when the first effect of the poison has gone off. The time that may elapse from the commencement of coma till death varies from a few minutes to days; death has occurred after a quarter of an hour, half an hour, and an hour. It has also been prolonged to three, four, and six days, during the whole of which the coma has continued. The average period may, however, be put at from six to ten hours.
§ 162. Post-mortem Appearances.—Cadaveric rigidity lasts tolerably long. Casper has seen it still existing nine days after death, and Seidel[151] seven days (in February). Putrefaction is retarded in those cases in which a very large dose has been taken, but this is not a very noticeable or constant characteristic. The pupils are mostly dilated. The smell of alcohol should be watched for; sometimes it is only present in cases where but a short time has elapsed between the taking of the poison and death; putrefaction may also conceal it, but under favourable circumstances, especially if the weather is cold, the alcoholic smell may remain a long time. Alcohol may cause the most intense redness and congestion of the stomach. The most inflamed stomach I ever saw, short of inflammation by the corrosive poisons, was that of a sailor, who died suddenly after a twenty-four hours’ drinking bout: all the organs of the body were fairly healthy, the man had suffered from no disease; analysis could detect no poison but alcohol; and the history of the case, moreover, proved clearly that it was a pure case of alcoholic poisoning.
[151] Seidel, Maschka’s Handbuch, Bd. ii. p. 380.
In a case related by Taylor, in which a child drank 4 ozs. of brandy and died, the mucous membrane of the stomach presented patches of intense redness, and in several places was thickened and softened, some portions being actually detached and hanging loose, and there were evident signs of extravasations of blood. The effect may not be confined to the stomach, but extend to the duodenum and even to the whole intestinal canal. The blood is generally dark and fluid, and usually the contents of the skull are markedly hyperæmic, the pia very full of blood, the sinuses and plexus gorged; occasionally, the brain-substance shows signs of unusual congestion; serum is often found in the ventricles. The great veins of the neck, the lungs, and the right side of the heart, are very often found full of blood, and the left side empty. Œdema of the lungs also occurs with tolerable frequency. The great veins of the abdomen are also filled with blood, and if the coma has been prolonged, the bladder will be distended with urine. A rare phenomenon has also been noticed—namely, the occurrence of blebs on the extremities, &c., just as if the part affected had been burnt or scalded. Lastly, with the changes directly due to the fatal dose may be included all those degenerations met with in the chronic drinker, provided the case had a history of previous intemperance.
§ 163. Excretion of Alcohol.—Alcohol, in the diluted form, is quickly absorbed by the blood-vessels of the stomach, &c., and circulates in the blood; but what becomes of it afterwards is by no means settled. I think there can be little doubt that the lungs are the main channels through which it is eliminated; with persons given up to habits of intemperance, the breath has constantly a very peculiar ethereal odour, probably dependent upon some highly volatile oxidised product of alcohol.
Alcohol is eliminated in small proportion only by the kidneys. Thudichum, in an experiment[152] by which 4000 grms. of absolute alcohol were consumed by thirty-three men, could only find in the collected urine 10 grms. of alcohol. The numerous experiments by Dupré also establish the same truth, that but a fraction of the total alcohol absorbed is excreted by the kidneys. According to Lallemand, Perrin, and Duroy the content of the brain in alcohol is more than that of the other organs. I have found also that the brain after death has a wonderful attraction for alcohol, and yields it up at a water-heat very slowly and with difficulty. In one experiment, in which a finely-divided portion of brain, which had been soaking in alcohol for many weeks, was submitted to a steam heat of 100°, twenty-four hours’ consecutive heating failed to expel every trace of spirit.
[152] See Thudichum’s Pathology of the Urine, London, 1877, in which both his own and Dr. Dupré’s experiments are summarised.
It is probable that true alcoholates of the chemical constituents of the brain are formed. In the case of vegetable colloidal bodies, such, for example, as the pulp of cherries, a similar attraction has been observed, the fruit condensing, as it were, the alcohol in its own tissues, and the outer liquid being of less alcoholic strength than that which can be expressed from the steeped cherries. Alcohol is also excreted by the sweat, and minute fractions have been found in the fæces.
§ 164. Toxicological Detection of Alcohol (see “Foods,” pp. 406-419).—The living cells of the body produce minute quantities of alcohol, as also some of the bacteria normally inhabiting the small intestine produce small quantities of alcohol, and it is often found in traces in putrefying fluids. Hence, mere qualitative proofs of the presence of alcohol are insufficient on which to base an opinion as to whether alcohol had been taken during life or not, and it will be necessary to estimate the quantity accurately by some of the processes detailed in “Foods,” p. 409, et seq. In those cases in which alcohol is found in quantity in the stomach, there can, of course, be no difficulty; in others, the whole of the alcohol may have been absorbed, and chemical evidence, unless extremely definite, must be supplemented by other facts.
2. AMYLIC ALCOHOL.
§ 165. Amylic Alcohol—Formula, C5H11HO.—There is more than one amylic alcohol according to theory; eight isomers are possible, and seven are known. The amylic alcohols are identical in their chemical composition, but differ in certain physical properties, primary amylic alcohol boiling at 137°, and iso-amyl alcohol at 131·6°. The latter has a specific gravity of ·8148, and is the variety produced by fermentation and present in fusel oil.
§ 166. The experiments of Eulenberg[153] on rabbits, Cross[154] on pigeons, Rabuteau[155] on frogs, and Furst on rabbits, with those of Sir B. W. Richardson[156] on various animals, have shown it to be a powerful poison, more especially if breathed in a state of vapour.
[153] Gewerbe Hygiene, 1876, p. 440.
[154] De l’Alcohol Amylique et Méthyl sur l’Organisme (Thèse), Strasburg, 1863.
[155] “Ueber die Wirkung des Aethyl, Butyl u. Amyl Alcohols,” L’Union, Nos. 90, 91, 1870. Schmidt’s Jahrb., Bd. 149, p. 263.
[156] Trans. Brit. Association, 1864, 1865, and 1866. Also, Brit. and Foreign Med. Chir. Rev., Jan. 7, 1867, p. 247.
Richardson, as the result of his investigations, considers that amyl alcohol when breathed sets up quite a peculiar class of symptoms which last for many hours, and are of such a character, that it might be thought impossible for the animal to recover, although they have not been known to prove fatal. There is muscular paralysis with paroxysms of tremulous convulsions; the spasms are excited by touching the animal, breathing upon it, or otherwise subjecting it to trifling excitation.
§ 167. Hitherto, neither the impure fusel oil, nor the purer chemical preparation, has had any toxicological importance. Should it be necessary at any time to recover small quantities from organic liquids, the easiest way is to shake the liquid up with chloroform, which readily dissolves amylic alcohol, and on evaporation leaves it in a state pure enough to be identified. Amyl alcohol is identified by the following tests:—(1) Its physical properties; (2) if warmed with twice its volume of strong sulphuric acid, a rose or red colour is produced; (3) heated with an acetate and strong sulphuric acid, amyl acetate, which has the odour of the jargonelle pear, is formed; (4) heated with sulphuric acid and potassic dichromate, valeric aldehyde is first produced, and then valeric acid is formed; the latter has a most peculiar and strong odour.
§ 168. Amyl Nitrite, Iso-amyl Ester Nitrite (C5H11NO2).—Boiling point 97° to 99°, specific gravity ·877. Amyl nitrite is a limpid, and, generally, slightly yellow liquid; it has a peculiar and characteristic odour. On heating with alcoholic potash, the products are nitrite of potash and amylic alcohol; the amylic alcohol may be distilled off and identified. The presence of a nitrite in the alkaline solution is readily shown by the colour produced, by adding a few drops of a solution of meta-phenylenediamine.
Sir B. W. Richardson and others have investigated the action of amyl nitrite, as well as that of the acetate and iodide; they all act in a similar manner, the nitrite being most potent. After absorption, the effects of amyl nitrite are especially seen on the heart and circulation: the heart acts violently, there is first dilatation of the capillaries, then this is followed by diminished action of the heart and contraction of the capillaries.
According to Richardson, it suspends the animation of frogs. No other substance known will thus suspend a frog’s animation for so long a time without killing it. Under favourable circumstances, the animal will remain apparently dead for many days, and yet recover. Warm-blooded animals may be thrown by amyl nitrite into a cataleptic condition. It is not an anæsthetic, and by its use consciousness is not destroyed, unless a condition approaching death be first produced. When this occurs there is rarely recovery, the animal passes into actual death.
Post-Mortem Appearances.—If administered quickly, the lungs and all the other organs are found blanched and free from blood, the right side of the heart gorged with blood, the left empty, the brain being free from congestion. If administered slowly, the brain is found congested, and there is blood both on the left and right sides of the heart.