{602} extremely rare. Even when simple or ulcerative inflammation of
the stomach is localized at, or extends to, the pylorus, it rarely
passes any great distance into the gut. The large intestine is, on the
contrary, frequently the seat of chronic inflammatory processes. Here
we find vascular engorgement, patches of pigmentation, localized
thickening of the mucous and submucous tissues, enlargement of the
solitary glands, and an excessive secretion of viscid mucus. The
tendency to permanent vascular dilatation, which is a characteristic
result of alcoholic habits, constitutes a powerful predisposing
influence in the causation of hemorrhoids, which are common. Alcohol
acts directly upon the hemorrhoidal plexus of veins, and indirectly by
causing permanent congestions of more or less intensity in the greater
number of the abdominal viscera. When a prolonged course of excesses
in alcohol has led to chronic congestion with hypertrophy, cirrhosis,
or other structural change in the liver which is capable of causing
permanent mechanical obstruction of the portal circulation,
hemorrhoids constitute a very common affection in the group of morbid
entities secondary to these conditions.
The symptoms of intestinal derangement are in the beginning, as a
rule, slight and occasional. They consist of uneasy sensations or
colicky pains in the abdomen, a feeling of fulness with or without
tympany, and constipation alternating with diarrhœa: in a word, they
are the symptoms of acute or subacute intestinal indigestion
terminating in an attack of intestinal catarrh. Attacks of this kind
repeat themselves in a considerable proportion of the cases with
variable but increasing frequency, until at length the conditions of
which they are the expression become permanent, and the patient
suffers, among other distressing symptoms hereafter to be described,
from chronic diarrhœa. The stools are now of the most variable
character—occasionally bilious, sometimes containing small dark
scybalous masses, rarely formed, but usually containing more or less
abnormal mucus, too much fluid, and traces of blood. Indeed, at this
stage several causes—among which I may mention visceral congestions,
local inflammation of the intestinal mucous membrane, dilatation of
the hemorrhoidal veins, and structural changes in the liver—conspire
to determine blood toward the interior of the intestinal tube. Traces
of blood in the stools are therefore frequent, and actual hemorrhage
and the appearance of the dark, tarry, and altered blood formerly
described under the term melæna are by no means rare. Colliquative
diarrhœa and dysenteric attacks also occur, and at length an intense
enteritis with uncontrollable diarrhœa may end the life of the
patient. The conditions just described lead to rapid emaciation, and
contribute when present to the establishment of the cachexia so marked
in many cases of chronic alcoholism.
The Glands.—The salivary glands were found by Lancereaux[32] to have
undergone softening, with granulo-fatty changes in their epithelium.
If such changes are among the usual effects of alcohol, they are
doubtless productive of alterations in the saliva, which explain, in
part at least, the dryness of the mouth so frequent among drunkards.
[Footnote 32: _Dictionnaire de Médecine_, art. “Alcoholism.”]
The pancreas is, as the result of interstitial inflammation, the seat
of similar changes. It is sometimes enlarged and softened, sometimes
atrophied, shrivelled, or cirrhotic. In the latter condition its
consistence is {603} firm, its surface uneven, its color deep yellow,
brown, or pale. Hyperplasia of the interacinous connective tissue,
with subsequent contraction and atrophy and destruction of the
glandular tissue, characterizes the more chronic forms of
pancreatitis, and the organ is frequently the seat of scattered minute
blood-extravasations. I have already alluded to the enlargement of the
solitary glands which constitutes a feature of the condition of the
large intestine. The solitary glands and Peyer's patches of the small
intestine are rarely altered.
_b_. Disorders of the Liver.—Next in order to the stomach, the liver
is more directly exposed to the action of alcohol than any other
viscus. For this reason lesions of the liver are frequent and grave.
It is worthy of note, however, that in a small proportion of cases of
chronic alcoholism terminating fatally, with widespread evidences of
the destructive action of alcohol upon the other organs of the body,
the liver has been found, both in its macroscopic and microscopic
appearances, wholly normal. Absorbed by the gastric vessels, alcohol
passes directly, by way of the portal vein, into the parenchyma of the
liver, there giving rise to various disturbances, the nature of which
is determined by the tendencies of the individual on the one hand, and
on the other hand by the character of the alcohol consumed. The danger
of hepatic disease is in direct proportion to the amount and the
concentration of the alcohol habitually taken. The steady drinkers of
spirits of whatever kind, whether gin, brandy, whiskey, or rum,
present the largest proportion of diseases of the liver. These
affections are far less common among beer-drinkers, and infrequent
among wine-drinkers in wine-growing countries. In this connection it
is to be borne in mind that the presence of food in the stomach
retards to some degree the absorption of the alcohol ingested, and to
a certain extent constitutes a means of dilution.
Hepatic disorders due to alcohol may be arranged in two groups: first,
congestion and inflammation; second, fatty infiltration or steatosis;
and the inflammatory process may affect chiefly the interstitial
connective tissue on the one hand, giving rise to sclerosis, or on the
other the glandular substance, constituting a true parenchymatous
inflammation.
Congestion.—Congestion of the liver is an early lesion. It is brought
about by the direct irritant action of the alcohol itself in part, and
in part by the extension of inflammation from the stomach by
continuous mucous tracts. Its development is insidious. Anatomically,
the condition is characterized by vascular dilatation, moderate
tumefaction, slight increase in the consistence of the organ; the
surface is of a deeper red than normal; on section the color is more
intense and the oozing more abundant. At a later period we have, as
the result of chronic congestion, the cyanotic liver; the color is
brownish or violet, mottled, and on section the surface is granular
and the lobules distinct. The organ may now be somewhat diminished in
size, but it lacks the firmness of sclerosis and the hobnail
appearance due to the contraction of the interlobular connective
tissue in that condition.
The symptoms of congestion of the liver are the familiar symptoms of
gastro-hepatic catarrh, varying from the transient disturbance known
as biliousness to serious sickness, characterized by acute
gastro-intestinal phenomena, with vomiting, headache, and other
derangements of the nervous system—constipation, succeeded by diarrhœa
and by more or less {604} distinct jaundice. The graver forms of
hepatic congestion are characterized by intense nausea, frequent
vomiting, pain and soreness in the epigastrium and right hypogastrium,
the physical signs of augmentation of the volume of the liver, and
well-marked yellow discoloration of the conjunctivæ and skin. These
attacks are usually afebrile: the pulse is slow; there is considerable
nervous and mental depression, a tendency to vertigo, and occasional
syncope. The urine is scanty and high-colored, and presents the
reactions of bile-pigment. Muscular tremor, especially marked in the
extremities and tongue, is often present, but is to be attributed
rather to the direct action of alcohol upon the nervous system than to
the condition of the liver.
Hepatitis.—There are two principal forms of inflammation of the liver
induced by alcohol—parenchymatous hepatitis and interstitial hepatitis
or sclerosis.
Several varieties of parenchymatous hepatitis have been described. The
anatomical discrimination of these varieties is attended with less
difficulty than their clinical diagnosis. One of the more serious is
diffused parenchymatous hepatitis or acute yellow atrophy. Alcoholic
excesses appear to constitute a predisposing influence to this grave
disorder (Lentz). In several cases prolonged and repeated excesses
have preceded its development. It is a true parenchymatous
inflammation, in which the glandular elements of the organ undergo
disintegration. The liver is diminished in volume in all its
diameters. It is of a uniform yellow color; its tissue is soft and
friable; upon section the hepatic cells are found to be replaced by a
granular detritus mingled with globules of coloring matter and a
greasy, grayish-yellow liquid exudation.
The symptoms of this affection are those of an acute parenchymatous
hepatitis of the gravest kind. In the early stages there is intense
jaundice, gastro-intestinal disturbance, and fever, followed by speedy
evidences of profound toxæmia. The patient rapidly falls into the
so-called typhoid state, with a tendency to coma. The prognosis is, in
the greater number or cases, a fatal one. So close is the resemblance
between acute yellow atrophy of the liver and the phenomena of acute
phosphorus-poisoning that by many observers these two conditions are
held to be identical.[33]
[Footnote 33: Consult this _System of Medicine_, Vol. II., article
“Acute Yellow Atrophy of the Liver.”]
There is little doubt that the view now generally held, that acute
yellow atrophy is due to the action of some unknown toxic principle,
is correct. Alcoholic excess must therefore be regarded merely in the
light of a predisposing influence. Acute yellow atrophy of the liver
is an exceedingly rare disease.
Suppurative Hepatitis.—Abscess of the liver is in temperate climates
infrequent as the direct result of alcoholic excess. It is frequently
ascribed, however, to improper alcoholic indulgence, especially when
combined with the eating of large quantities of improper food, in
tropical and subtropical climates. A form of hepatitis has been
described by Leudet under the head of chronic interstitial hepatitis
with atrophy. The symptoms are for the most part not very well marked,
and consist chiefly in general malnutrition, which may in fact be
dependent upon the associated gastric disturbance. Chronic jaundice is
usually present.
Interstitial Hepatitis.—Cirrhosis of the liver is in a large
proportion of cases directly attributable to alcoholic excess. In this
view the greater {605} number of observers coincide. But that alcohol
is not the sole cause of chronic interstitial hepatitis has been
abundantly established. As long ago as 1868, Anstie[34] wrote as
follows: “Considering the enormous quantities of spirituous liquors
which are drunk by many of the patients who apply for relief from the
consequences of chronic alcoholism, it would be natural for the reader
who holds the usual opinion as to the origin of cirrhosis of the liver
to expect that serious symptoms produced by the latter disorder must
often complicate cases of the former. The case is, however, far
otherwise in my own experience. Of the immense number of patients in
whom the nervous disorder has been clearly identified, I have only
seen thirteen cases in which the symptoms of cirrhotic disease called
for any special treatment, although a certain degree of cirrhosis was
doubtless present in many of the others; and I cannot avoid the
conclusion that some very powerful element over and above the
influence of alcoholic excess is needed to produce the severe type of
that disease.” Formad[35] states as the result of his investigations
as coroner's physician of the city of Philadelphia that cirrhosis of
the liver is much less common in alcoholic subjects than has been
generally thought. My own experience during eleven years as attending
physician at the Philadelphia Hospital leads me to endorse this
opinion.
[Footnote 34: _A System of Medicine_, Reynolds, vol. ii. p. 74.]
[Footnote 35: _Proceedings of the Pathological Society of
Philadelphia_, Dec., 1885.]
The anatomical lesions of chronic interstitial hepatitis consist
essentially in hyperplasia and hypertrophy of the connective tissue of
the organ. The progress of the affection is insidious and gradual;
some degree of enlargement, due in part to congestion and in part to
interstitial exudation, is followed by gradual diminution, with
retraction of the new connective tissue. When the connective-tissue
new formation is excessive, and retraction fails to take place, the
organ remains permanently enlarged (hypertrophic cirrhosis). During
the first period the volume of the organ is increased, its consistence
is more firm, and its surface is slightly granular. The second period
is characterized by induration, with diminution of the volume of the
organ and alteration of its form. The surface is uneven, deeply
granular, and usually of a mottled yellow color. The tissue is firm,
creaking under the knife. The connective tissue is enormously
increased, the glandular elements being proportionately atrophied.
The contracting connective tissue exercises at the same time a
compressing influence upon the hepatic cells and upon the vascular
supply throughout the organ; the radicals of the portal vein and the
branches of the hepatic artery are alike compressed, and in part
obliterated. The same is true of the bile-ducts. The functional
activity of the liver, at first diminished, is finally, to a
considerable extent, arrested. In consequence of these physical
alterations in the structure of the organ, the symptoms, which are at
first insignificant, become progressively more grave, until at length
they constitute complications of the most serious kind.
It can be no longer asserted that the interstitial hepatitis produced
by alcohol presents specific characters. It nevertheless differs in
many respects from that form due to valvular lesions of the heart, in
which there are induration, usually augmentation in the volume of the
organ, {606} and persistent congestion. Congestion, in truth, is the
chief characteristic of the latter form, in which the surface is
smooth and glistening, of a deep brown or violet hue, and on section
yellowish or brown—a condition which has been well described under the
term cyanotic liver.
Sclerotic changes due to alcohol usually affect the organ throughout.
In this respect alcoholic cirrhosis differs from that form due to
syphilis in which the lesions are irregularly distributed.
The functional disturbances due to cirrhosis are, in the beginning,
obscure in themselves and masked by the concomitant gastric
derangement. Later, ascites constitutes the chief as well as the most
constant symptom. It is rarely altogether absent. Emaciation is also a
prominent symptom. No affection, not even diabetes or phthisis,
produces loss of flesh so rapid, so marked, and so significant as
cirrhosis of the liver in chronic alcoholism. Not only do the adipose
tissues waste, but the muscles themselves undergo rapid atrophy. This
fact is not surprising when we consider that the lesions of the liver
give rise to grave interference with every function of that organ. In
addition to the more common gastric symptoms, there is constipation,
not rarely alternating, without assignable cause, with serous and
sometimes bloody diarrhœa. Epigastric distress, epistaxis, and
hemorrhages from other mucous surfaces are common, and are due in part
to the disturbance of the general circulation, and in part to
alterations in the character of the blood itself. The physical signs
indicate in the early stages increase, and afterward diminution, in
the volume of the liver. Enlargement of the superficial abdominal
veins is a characteristic sign. Cirrhosis of the liver is a grave
affection, the course of which, at first slow, afterward more rapid,
almost invariably leads to a fatal termination.
Fatty Degeneration of the Liver.—Steatosis of the liver is of
extremely common occurrence in the advanced stages of alcoholism. The
anatomical changes consist in accumulation of fat-globules in the
liver-cells. French writers distinguish two varieties of hepatic
steatosis: first, that in which the cellular elements undergo no
change beyond that of an accumulation of fat-globules within their
substance; and second, that in which the liver-cells undergo an actual
disintegration, in the course of which fat-granules are formed, and
which is, as a matter of fact, a true fatty degeneration. The first of
these conditions is not incompatible with the functional integrity of
the organ, and is in many instances unattended by symptoms, being
discovered only upon examination after death. Its occurrence is to be
explained by the imperfect oxidation of waste products due to the
constant presence of alcohol in the blood, and by the habitual excess
of fat in the latter fluid. When fatty infiltration is of moderate
amount there are no changes in the volume or the contour of the organ,
and the condition is recognized only on microscopical examination. At
a later stage the organ becomes enlarged, particularly in its
antero-posterior diameter. The surface is now smooth and glistening,
its color yellow or reddish-yellow; upon section it is anæmic, of a
yellowish color, with patches of a reddish hue, and its consistence is
diminished. The indentation caused by pressure of the finger persists.
Under the microscope the hepatic cells are enlarged, rounded, packed
with fat-globules of varying size. In some of the cells these globules
coalesce and form more or less extensive drops of fat. The bile which
is {607} secreted in this condition presents in most instances the
normal characteristics.
Disorders of digestion do not occur in consequence of the fatty change
in the liver until the lesion has reached an advanced stage;
nevertheless, they constitute the earliest symptoms of this condition.
Imperfect digestion, accompanied with flatulence, distension of the
belly, epigastric tenderness, with light-colored stools, and
constipation alternating with diarrhœa, are common symptoms. There is
no pain properly referable to the region of the liver. Whilst icterus
does not occur, there is, nevertheless, a peculiar earthy pallor of
the complexion and persistent greasiness of the skin—conditions,
however, which are not in themselves sufficiently marked to possess,
in the absence of other signs, clinical value.
The second form of fatty degeneration, in which the liver-cells
undergo actual and destructive metamorphosis, accompanied by the
production of fat, is of a much more serious character. It appears to
constitute the stadium ultimum of various forms of interstitial
hepatitis, and is manifested by symptoms of the gravest character, in
many particulars much like those met with in acute yellow
atrophy—namely, visceral congestions, hemorrhages from mucous
surfaces, serous effusions, profound and rapidly developing anæmia,
nervous depression, and coma.
Biliary Catarrh.—The biliary ducts are usually the seat of catarrhal
inflammation, due less perhaps to the direct irritant action of the
alcohol than to the extension of the inflammation of the gastric
mucous membrane in the form of gastro-duodenal catarrh. Gall-stones
are not common in alcoholism.
The spleen is, as a rule, enlarged, soft, and friable; occasionally it
is small and shrivelled. No characteristic changes in its contour and
structure have been recorded.
The great omentum and mesentery are loaded with fat, very often to an
extreme degree. This condition is more marked in the chronic
alcoholism of beer-drinkers than in that of spirit-drinkers. Not
infrequently there are found evidences of chronic peritonitis, which
has been attributed by Lancereaux, in the absence of other assignable
cause, to the effect of alcohol itself. The symptoms of this condition
are usually obscure, consisting of diffused dull pain, augmented upon
pressure, diarrhœa, digestive troubles, and abdominal distension,
sometimes voluminous, often irregular.
_c_. Disorders of the Respiratory System.—The Larynx.—Catarrhal
inflammation of the mucous membrane of the air-passages is common in
drunkards. Some degree of subacute or chronic laryngitis is an early
symptom of chronic alcoholism. It may result from repeated attacks of
acute alcoholism, or it may be among the first signs of excesses that
are continuous, without at any one time being extreme. In the
production of this local trouble the direct action of alcohol is
reinforced by the foul and smoke-laden air of the apartments in which
tipplers spend much of their time and by heedless exposure to the
vicissitudes of the weather. The anatomical changes are those of
chronic laryngitis in general, hyperæmia of the mucous membrane with
minute ecchymoses, local destruction of epithelium with superficial
ulcerations or granulating surfaces. The mucus is often thick, opaque,
and adherent.
{608} These lesions are accompanied by more or less decided impairment
of function. The voice is hoarse and husky; there is fatiguing
laryngeal cough, usually harsh and grating in character, and attended
by scanty muco-purulent expectoration. This cough is often paroxysmal;
especially is it apt to be so on rising, and it then provokes the
vomiting previously described.
The Bronchi.—After a time similar anatomical changes are brought to
pass in the bronchial tubes. Subacute bronchitis is little by little
transformed into the chronic form, characterized by hyperæmia and
thickening of the mucous membrane, extending to the finer twigs, with
submucous infiltration and implication of the connective-tissue
framework of the lung. The exudation, tough and adherent or fluid and
copious, occasions more or less frequent cough, and interferes with
the function of respiration. Hence it is common to encounter in the
subjects of chronic alcoholism bronchiectasis, pseudo-hypertrophic
emphysema, easily excited or permanent dyspnœa, asthmatic seizures,
and some degree of cyanosis. These local affections, interfering with
the circulation of the blood and its proper aëration, react
unfavorably upon the nutrition of the organism at large, and largely
contribute to the production of the ultimate dyscrasia.
The Lungs.—Pulmonary congestion and œdema are of common occurrence.
Favored by the action of alcohol upon the vaso-motor system, they are
readily excited by the careless habits and frequent exposures of the
subject. The lesions occupy by preference the lower and posterior
parts of the lungs, and consist in relaxation of the parenchyma, with
vascular dilatation and serous infiltration. The vesicles are capable
of distension, but contain little air. The tissue is friable, deep-red
or brownish in color, and floats upon water. The symptoms of this
condition are sometimes obscure: usually they consist in a sensation
of constriction of the thorax, more or less dyspnœa, mucous
expectoration, sometimes streaked with blood, and lividity of the
countenance and finger-tips. The chief physical signs are impaired
percussion resonance and mucous, subcrepitant, and occasionally a few
scattered crepitant râles.
Pulmonary Apoplexy.—When the congestion is extreme, blood may escape
into the parenchyma of the lung with laceration of its substance. This
lesion is more frequent in intense acute alcoholism than in the
chronic form.