Evaluation of Drunkenness

Evaluation of Drunkenness

Drunkenness is a condition produced in a person, who has taken alcohol in a quantity sufficient to cause him to lose control of his faculties to such an extent, that he is unable to execute safely, the occupation in which he was engaged at the particular time.


The clinical diagnosis depends on the combination of a number of symptoms and signs, no single one of them being peculiar to this condition, except the odor of alcohol from the breath. An individual can react differently under different circumstances, and that the same amount of alcohol can produce different effects on different people under the same circumstances. Mentally unstable subjects, epileptics and those who have suffered .cerebral trauma -at some earlier date may show an excessive reaction to small amounts of alcohol.

A Model Scheme of Medical Examination: The scheme of examination of an alleged alcoholic has been suggested by the Special Committee of the British Medical Association, "The Drinking Driver", 1965. The medical examiner's record should include a note of the date and of the time at the beginning and at the end of the examination.

(1) Exclusion of Injuries and Pathological States:

The following conditions which simulate alcoholic intoxication should be excluded :

(a)Severe head injuries,

(b) Metabolic disorders, e.g.hypoglycemia,diabetic pre-coma, uremia,hyperthyroidism.

(c) Neurological conditions,e.g. disseminated sclerosis,intracranial tumors,Parkinson's disease, epilepsy, acute aural vertigo,

(d) Drugs: Insulin, barbiturates, antihistamines,morphine, atropine, hyoscine..Drugs capable of producing sedation or depression of the nervous system (antihistaminic, tranquillizers), will simulate or enhance the effects of alcohol,

(e) Certain preexisting psychological disorders, e.g. hypomania,general paresis,

(f) High fever,

(g) Exposure to CO.

(2) History:

The history of the relevant events should be obtained from the accused person while observing him.Enquire whether he suffers
from any disease or disability and whether he is under medical treatment.

(3) General Behavior:

(a) General manners and behavior,

(b) State of dress: Presence of slobber on mouth or clothing; presence, character and color of any vomit, soiling of clothes by excretions,

(c) Speech: Note the type, e.g.is it thick, slurred or over-precise? Slight blurring of certain consonants is one of the earliest signs of in coordination of the muscles of the tongue and lips. Certain test phrases may be used to bring out this
difficulty in speech, such as 'British Constitution', West Register Street,Truly Rural',etc.A sober person will say that he is not good at such phrases; the semi-intoxicated person will often insist on getting them correctly,

(d) Self-control.: Note whether he is able to control himself in response to the demands made on him by the examiner.

(4) Memory and Mental Alertness:

The memory of the person for recent events, and his appreciation of time can be judged by asking suitable questions about his movements during the preceding few hours, and the details of his accident if any. A few very simple sums of addition or subtraction may be asked.

(5)Handwriting:

The examinees should be asked to copy a few lines from a newspaper or book. A note should be made of:

(a) The time taken,

(b) Repetition or omission of words,letters, or lines,

(c) Ability to read his own writing. Both the original and the copy should be retained. The examinees should be asked to sign his name.The signature can be compared with that on his driving license if any.

(6) Pulse:

The resting pulse should be taken at the beginning and at the end of the examination.The pulse is rapid and is usually full and bounding. A slight increase in B.P. may occur, often in the systolic level.

(7) Temperature:

The surface temperature is usually raised.

(8) Skin:

Note whether skin is dry, moist,flushed or pale.Skin is warm, dry and flushed in drunkenness.

(9) Mouth:

(a) Record the general state of mouth, teeth and tongue, noting whether the tongue is dry, furred or bitten,

(b) The smell of the breath should be recorded.

(10) Eyes:

(a) General appearance :

(1) Whether the lids are swollen or red, and whether the conjunctiva are congested.

(2) The color of the eyes, and abnormalities.

(b) Visual acuity: Any gross defect should be noted.

(c) Intrinsic muscles:

(1) Pupils: Equal or unequal, dilated or contracted or abnormal in any way(usually dilated in early stages, but may be
contracted in later stages or coma).

(2) Reaction to light : Note whether the action is brisk, slow or absent. They may become unequal, equalizing again
in response to light, and dilate again slowly even if the light continues to be directed into the eyes.

(d) Extrinsic muscles:

(1) Convergence: Test the degree of ability to follow a finger in all normal directions and to converge the eyes normally
on a near object.

(2) Strabismus : Note whether it is present.

(3) Nystagmus : The presence of fine lateral nystagmus may indicate alcoholic intoxication. Nystagmus may be produced by fatigue, emotion or postural hypotension.

(11) Ears:

Examine for (a) Gross impairment of hearing, (b) Abnormality of the drums.

(12) Gait:

The integrity of the nervous and muscular system is tested for the coordination of fine and gross movements, e.g. balance, gait and speech. The examinees should be asked to walk across the room and note:

(a) Manner of walking: Is it straight, irregular, over precise, unsteady, or with feet wide apart?

(b) Reaction time to a direction to turn: Does the examinees turn at once or continue for one or two steps before obeying?

(c) Manner of turning : Does the examinees keep his balance, lurch forward, or reel to one side? Does he correct any mistake in a normal or exaggerated way? It is undesirable to ask the examinees to walk along a straight line drawn on the floor.

(13)Stance :Note whether the examinees can stand with his eyes closed and heels together without swaying.

(14) Muscular Coordination :

Ask the examinees to perform the following tests:

(a) Placing finger to nose,

(b) Placing finger to finger,

(c) Picking up medium-sized objects from the floor,

(d) Lighting a cigarette with a match,

(e) Unbuttoning and rebuttoning coat.

(f) Lifting two objects, such as tumblers from the table, and replacing them side by side on the table.

The examiner should not ask the examinees to perform any act which he could not perform easily himself. He should also appreciate the difficulty involved for some people in apparently simple movements, such as picking up small objects from the floor. A chronic alcoholic when sober may not be able to perform tests for coordination as well as when he has actually consumed alcohol.

(15) Reflexes :

Knee and ankle reflexes should be tested which are delayed or sluggish.Plantar reflex may be extensor or flexor.

(16)Pulmonary, Cardiovascular and Alimentary Systems:

The heart, lungs and abdomen should be examined, and the blood pressure taken to establish the presence or absence of disease.

(17) Tests:

Some of the following objective tests are useful; flicker fusion test, measurements of tremor during standing, oscillations during forced imbalance, pupillary reflex time, speed of spinal reflexes, presence of random ocular movements with closed eye, nerve conduction speed, complex reaction time, delayed auditory feedback, positional nystagmus, glare recovery test, color difference threshold, etc.

(18) Laboratory Investigations:

The degree of intoxication can be estimated by the concentration of alcohol in the blood, urine, breath, or saliva. In fatal accidents with partial body destruction, muscle or the fluid in the eye can be analyzed. Vitreous humour and urine are protected from putrefactive processes for a longer period of time and do not contain much glucose. Blood is the most suitable and the most direct evidence of the concentration of alcohol in the brain.

The disadvantages are: (1) it may be difficult to collect from an uncooperative person, (2) consent of the person is necessary, (3) substances like acetone, ether, paraldehyde, etc. when present in the blood are estimated as alcohol.

URINE : Urine has about 25% more water than an equal volume of blood, so its concentration I of alcohol would be about 25% higher than in blood collected at the same time. As the urine is secreted, its water will have essentially the same alcohol concentration as the water of the blood passing through the kidney. If the bladder contains urine before drinking began, urine secreted during or after the period will be diluted with the alcohol-free urine. If the bladder was empty when drinking began, urine secreted after some time will reflect the blood concentration of alcohol at that time. In order to compare the urine and blood, a ratio of 1.3:1.0 is usually accepted when urine and blood are in equilibrium.

Analysis of two urine samples are required. The first sample should be taken as soon as possible following the incident, the bladder being completely emptied. The second sample should be taken 25 to 30 minutes later. The concentration of alcohol in the second specimen reflects the blood alcohol level during the inter-specimen interval. The difference in the alcohol concentrations in the two samples indicates whether the subject was in the absorptive phase, at its peak, or, in the elimination phase. Multiplication of alcohol concentration in the second urine specimen by 0.75 (based on a bio urine alcohol ratio of 1:1.35) gives an approximate value of the blood alcohol level, during the time that this specimen was being secreted.

The disadvantages of urine examination are: (1) A time lag before equilibrium between blood and urine is reached; the maximum concentration is reached about twenty to twenty-five minutes later than in blood. (2) The urine alcohol concentration at any given time after the maximum concentration in blood has been reached will be higher by twenty to thirty percent than in the blood, because the specimen of urine examined will have been secreted from the blood at some earlier period. (3) Alcohol may pass through the lining of the bladder in either direction both in life and after death, depending on the relative concentration of alcohol in blood and urine.

Collection of Blood:

Spirit must not be used for cleaning the skin, and the syringe must be free from any trace of alcohol. The skin is cleaned with a solution of 1:1000 mercuric chloride or washed with soap and water. Blood samples should be preserved by the addition of hundred mg. of sodium fluoride for ten ml., followed by thorough shaking. This prevents loss of alcohol by glycolysis and bacterial action. Such samples will maintain alcohol concentration for several weeks ,even at room temperature. Hundred mg. of phenyl mercuric nitrate or sodium azide can also be used, as a preservative for 10 ml of blood or urine.

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