than others. It has even been asserted that alcohol is of itself
capable of acting as an efficient exciting cause. Whilst it is
indisputable that the action of this agent upon the pulmonary
blood-vessels and in favoring pulmonary congestion constitutes a
powerful predisposing influence, it cannot be admitted, regard being
had to the fact that it is largely eliminated by the lungs, that
alcohol can, in the absence of a specific cause, ever produce a
specific acute febrile disease, such as croupous pneumonia. The
pneumonia of alcoholic subjects, like that of aged persons and that
occurring in the convalescence from acute diseases, is apt to be
latent. The exudation is often of limited extent; the symptoms are
insidious, and the striking clinical features of the ordinary frank
form of the affection are not rarely absent altogether. It is no
infrequent occurrence that pneumonia is overlooked in the delirium
tremens which it has induced.
The anatomical changes are those of the ordinary form. The prognosis
{609} is always grave. When recovery occurs resolution is often
tedious and prolonged.
Catarrhal pneumonia is also common. It is marked by its usual
phenomena.
The most striking fact in the pneumonia of alcoholic individuals is
the contrast between the local and the constitutional symptoms. The
former are in the greater number of the cases insignificant and easily
overlooked. Even the physical signs, when sought for, are often
obscure and indeterminate: relative dulness, enfeebled or absent
vesicular murmur, faint scattered crepitation masked by mucous râles,
and a bronchial respiratory sound scarcely appreciable, are all that
can be detected upon physical examination. In strong contrast to this
almost negative picture is that of the constitutional disturbance,
which is commonly of the gravest kind. The prostration is extreme;
there is delirium with tremor, restlessness, sleeplessness, mental
agitation, profuse sweating, feeble action of the heart,
gastro-intestinal irritation, with vomiting and often complete
inability to retain food. The temperature-curve lacks the characters
of pneumonia of the ordinary form. Not seldom is febrile movement
absent altogether.
The view that alcohol, independently of and in the absence of other
lesions, occasionally produces changes in the lungs analogous to the
chronic interstitial inflammatory processes of cirrhosis of the
liver—_i.e._ fibroid phthisis—is not borne out by clinical or
pathological investigation, and appears to be wholly without
foundation in fact.
Pulmonary Phthisis.—The question whether or not chronic alcoholism
exerts any influence in the production and evolution of pulmonary
phthisis has been the subject of no little fruitless controversy.
There are medical men of experience who do not hesitate to affirm that
the abundant use of alcohol constitutes in certain cases an actual
prophylaxis, while there are others who insist with equal positiveness
that alcoholic excesses favor the development of this affection.
Whatever may be the influence of alcohol in depressing the forces of
the body and in the production of serious lesions of pulmonary
structures, and thus predisposing the subject to phthisis, it can be
asserted with confidence that it does not directly cause any form of
phthisis whatever. The alcoholic phthisis of Lancereaux, Richardson,
Drysdale, and others cannot be now regarded as a distinct, independent
affection. The process of exclusion by which alcohol was made to seem
the real cause of the disease in 36 of 2000 of the cases examined by
Richardson was not sufficiently rigid to meet the requirements of our
present knowledge. There is reason to believe that by its favorable
influence upon the appetite and digestion, its power to reduce
temperature, its retarding influence upon tissue-waste, alcohol in
moderate quantities is of great use in the management of this
affection. That phthisical subjects occasionally seem to derive
benefit from, and to lengthen their lives by, excesses in alcohol is
capable of explanation—first, by the fact that an extraordinary
tolerance for alcohol is natural to or acquired by certain
individuals; and, second, by the favorable influence of alcohol upon
ulcerative and suppurative processes, and in determining
connective-tissue new formation—a process by which certain
inflammatory products, including tubercle, are capable of being
rendered inert. The foregoing remarks are applicable to all forms of
pulmonary phthisis.
{610} The Pleuræ.—The pleura is sometimes the seat of patches of
fibrinous exudation of varying extent and thickness, which are,
according to Lentz, the expression of the formative action which
constitutes one of the modalities of alcoholism, and which are of the
same nature as the fibrinous exudations which occur in the peritoneum
and the dura mater. These false membranes cause pleural adhesions, and
occasionally contain within their meshes a turbid serous fluid.
_d_. Disorders of the Circulatory System.—The Heart.—This organ is
usually implicated to a greater or less extent in the course of
chronic alcoholism. Lesions of the muscular substance are more common
than those of the valvular apparatus.
Hypertrophy is common. It affects usually both sides of the heart—the
left, however, more than the right—and is associated with some degree
of dilatation. The part played by alcohol in the production of cardiac
hypertrophy is a dual one: first, that of constantly-repeated direct
stimulation of the heart; second, that of the indirect stimulation to
over-action caused by the necessity to overcome the obstacles which
the lesions of the viscera interpose to the circulation of the blood
in the later periods of the disease. Nor are the lesions of the
blood-vessels themselves, hereafter to be described, without influence
in inducing hypertrophy. Bollinger and Schmidbauer have shown that the
habitual consumption of beer in excessive quantities leads to cardiac
hypertrophy of characteristic form. Both sides of the heart
participate in the overgrowth: there is enormous increase in the
volume of the primitive muscular elements, with enlargement of the
nuclei. Whether or not actual numerical increase in the muscular
fibres takes place cannot be determined. This form of enlargement of
the heart occurs in the absence of lesions of the valves, disturbances
of the pulmonary circulation, arterial sclerosis, atheroma, or
granular kidneys. Some few of these cases of so-called idiopathic
hypertrophy are perhaps due to prolonged excessive bodily effort and
bodily strain. But the greater number are only to be explained by
habitual excesses in beer-drinking, as shown by carefully worked-out
personal histories of the patients. Neither fatty degeneration nor
myocarditis enters into the pathological process under consideration.
The hypertrophy is due to the direct action of the alcohol consumed,
to the enormous amount of fluid introduced into the body, and to the
easily-assimilated nutritive constituents of the beer itself.
Furthermore, such habits are often associated with great bodily
activity and a relatively luxurious manner of life. The greater number
of alcoholic subjects who suffer from this form of hypertrophy perish
after brief illness with symptoms of heart-failure. At the necropsy
are discovered moderate dropsy, congestion and brown induration of the
lungs, congestion of the liver, spleen, kidneys, and other organs,
bronchitis and moderate serous effusions or general anasarca. Death is
probably due to paralysis of the cardiac nerves and ganglia. This form
of hypertrophy is of course much more common among men than among
women. It is much less common in this country than in Germany, but is
occasionally met with among brewers' employés.
Fibroid Degeneration.—This condition has been ascribed to a number of
causes, among which long-continued excess in alcohol is unquestionably
an important one. Bramwell holds the opinion that in a certain {611}
proportion of cases of this description, in which fibroid degeneration
of the heart is connected with similar changes in the kidneys
(sclerosis), the lesions of both organs are due to alcoholism.
Alcoholic fibrosis differs in no respect from that due to other
causes. The condition may escape recognition by the unaided eye if it
be disseminated throughout the muscle and the change consist in
thickening of the perimysia around undivided fibres. The heart is
larger than normal, perhaps a little paler, and its consistency a
little more firm. When, as is more commonly the case, the fibroid
change is localized, and masses of new tissue are developed in and
around the muscular fibres, the heart assumes a flecked or streaked
appearance, due to the contrast between the yellowish-white fibroid
tissue and the brownish-red muscular structure. The microscope shows
excessive development of fibrous tissue, with atrophy of muscular
fibres. The effect is to weaken the force of the heart's action, and
to weaken the walls of the cavities at the affected parts in such a
manner as to cause local bulgings or cardiac aneurisms.
The symptoms and physical signs of fibroid degeneration of the heart
are very obscure and indefinite, and the diagnosis is always attended
with difficulty, and in many cases is impossible. Jubel-Renoy,
however, regards the diagnosis as having already attained some
clinical exactitude, and regards as important the association of the
following diagnostic data: first, feebleness of the systole and the
pulse, with augmentation of the frequency without irregularity;
second, moderate enlargement, varying within considerable limits; and
third, absence of murmurs in the greater number of the cases. Death is
apt to occur suddenly. Welch, upon investigation of the clinical
histories of cases in which fibroid degeneration of the heart was
found after death, concluded that they might be clinically grouped as
follows: first, cases in which there is no symptom of heart disease;
second, cases of sudden death without previous heart symptoms; third,
sudden death preceded by one or more attacks of angina pectoris;
fourth, after cardiac insufficiency of a few days' standing; and
fifth, in cases of old heart disease.
Fatty Heart.—Under the term fatty heart two distinct pathological
conditions are comprised. Of these the first is fatty infiltration,
which consists in an excessive development of the normal
subpericardial fat, with a deposition of fat-cells in considerable
number between the muscular fibres of the myocardium. This condition
occurs chiefly in individuals suffering from general obesity, and is
particularly apt to occur in alcoholic obesity. Large masses of fat
fill the grooves and furrows of the organ, the surface of which is
covered with a thick layer of yellowish fat. The right heart is first
and most affected, but in advanced cases the whole heart may be
encased in a thick fatty layer. When the fat-cells infiltrate the
intermuscular spaces, they exert pressure which may produce atrophy
and degeneration of the muscular elements. This condition may exist to
a certain extent without symptoms, but it is, however, apt to be
manifested by a certain amount of cardiac dyspnœa and inability to
endure excessive strain or acute illness. In cases in which the fatty
infiltration attains a high grade, inducing by mechanical pressure
degenerative changes in the muscular substance of the heart, there are
signs of embarrassment of the circulation. The precise diagnosis is
usually difficult, often impossible.
{612} The second form of fatty heart is known as fatty degeneration,
and consists in changes in the muscular fibres by which the albuminoid
constituents are broken up and replaced by microscopic particles of
fat. After a time the transverse striæ disappear, and the functional
activity of those muscular fibres which are affected is completely
lost. All conditions which interfere with the supply of oxygen to the
muscular tissue or which seriously derange its nutrition are capable
of producing fatty degeneration. Among these are alcoholic excesses.
The color of the heart is paler than normal, usually fawn or pale
buff. It has been described as the faded-leaf color. The consistence
is softer than normal, the wall of the heart in many instances being
readily broken down by the pressure of the finger. The left ventricle
is the part most likely to be affected, the papillary muscles being
often profoundly altered. Next in order the right ventricle is
involved, then the left auricle, and finally the right auricle. When
this form of degeneration is due to disease of the coronary arteries,
the lesion is usually localized, sometimes limited to the distribution
of the branch of the artery which is affected.
Upon microscopical examination the affected muscular fibres are found
to contain minute molecules of fat, often of a uniform size, sometimes
arranged in rows, but commonly distributed irregularly throughout the
substance of the fibre. The transverse striæ are indistinct, and
sometimes wholly absent. The functional activity of the affected
fibres is seriously interfered with or wholly lost, and as a result
the force of the circulation is greatly weakened. These two forms of
fatty change are occasionally associated. Among the more common
symptoms are shortness of breath upon exertion, with dry hacking
cough. In advanced cases the dyspnœa may become constant. The fatal
issue is sometimes preceded by the Cheyne-Stokes respiration. Other
symptoms are due to cerebral anæmia. The memory is impaired, the
patient becomes wayward and irritable, and is apt to become faint upon
suddenly changing from the recumbent to the erect posture, and in most
instances is incapable of concentrated mental effort or active bodily
exertion.
The Blood-vessels.—Capillary dilatation is one of the earliest and
most persistent effects of alcohol. The visceral congestions which
constitute so important a factor in the pathology of alcoholism are in
part the result of the paralyzing action of alcohol on the vaso-motor
system, and in part of the degenerative changes in the unstriped
muscular fibres of the arterial walls.
Atheroma.—Alcoholic excesses play an important part in the etiology of
atheromatous degeneration of the arterial walls, not so much by the
direct action of the alcohol itself, as by its indirect action in
increasing the tension in the main trunks, and in leading to an
irregular life in which excitement, sudden and severe exertion,
exposure to cold, and depressing influences of all kinds play a part.
Valvular lesions of the heart do not occur as a direct result of the
action of alcohol.
_e_. Disorders of the Genito-urinary Apparatus.—The Kidneys.—Alcohol,
as has been shown above, is a diuretic. In large doses it produces
renal congestion. Ollivier[36] observed acute transient albuminuria
resulting from the influence of excessive doses of alcohol.
[Footnote 36: _Essai sur les Albuminuries produites par l'Elimination
des Substances toxiques_, Paris, 1863.]
{613} Much difference of opinion exists as to the part played by
alcohol in the causation of the various forms of Bright's disease. It
was at one time thought that a large proportion of the cases were due
to the abuse of this substance. Bright held this view, and Christison
attributed from three-fourths to four-fifths of all cases of granular
degeneration of the kidneys to the abuse of spirits. The latter
considered that not alone in notorious drunkards was this result
likely to occur, but even in those accustomed to the moderate daily
consumption of spirits with only occasional excesses. This opinion for
a long time largely prevailed among English writers. Of late years,
however, in consequence partly of the teachings of Anstie and
Dickinson, partly of more precise methods of reasoning, the direct
causative relation between chronic alcoholism and disease of the
kidneys has come to be questioned. Nevertheless, many teachers of
authority adhere to the former view. It is, however, more than
probable that the action of alcohol is not of itself capable of
producing these effects in the absence of other causes, among which
are insufficient or improper diet, irregular living, damp
dwelling-places, occupations necessitating great or prolonged exposure
to cold and wet or such exposure from accidental causes—circumstances
to which those who, especially among the poorer classes, are addicted
to drink are peculiarly liable. Nor must we overlook the influence of
exposure to paludal poison, of lead, and of heredity in the causation
of diseases of the kidneys. While alcohol cannot be regarded as the
direct exciting cause of acute or chronic nephritis, chronic
alcoholism acts as an influence predisposing to the development of
these affections in persons otherwise liable to them.
Congestion of the Kidneys.—The general action of alcohol in inducing
visceral hyperæmia is aided by its special diuretic action in causing
chronic congestion (cyanotic kidney). The kidney is of a dark
violet-red hue, slightly enlarged, especially in its transverse
diameter, of a consistence firmer than normal, and bleeds freely upon
section.
Acute parenchymatous nephritis is of rare occurrence in chronic
alcoholism. Of chronic parenchymatous nephritis Bartels[37] writes: “I
may say that alcoholic excesses, to which the disease is by many
attributed, cannot be charged with being the cause of it. None of the
cases treated by me occurred in drunkards, and in no instance have I
encountered the large white kidney at the autopsies of notorious
drinkers, of which I have made a not inconsiderable number during my
many years' active hospital service.” The same author in discussing
the etiology of chronic interstitial nephritis (contracted kidney)
enters a protest against the view which is widespread in England that
the abuse of spirituous liquors favors the development of the genuine
contracted kidney. He says: “In the first place, among all the
patients whom I have treated, three only were brandy-drinkers to any
notorious excess, while by far the greater number who were affected
with this complaint had lived remarkably abstemious lives. In the
second place, throughout my twenty-five years of active service as a
hospital physician I have had the most abundant opportunity of
watching the consequences of intemperance, both at the bedside and
upon the post-mortem table; yet these three cases have hitherto been
the only ones in which I have found atrophied {614} kidneys in the
bodies of habitual drunkards.” Baer also testifies to the infrequency
of contracted kidneys among drunkards.
[Footnote 37: _Ziemssen's Cyclopædia of Medicine_.]
Fürstner detected by very exact testing a trace of albumen in the
urine of almost all cases of delirium tremens examined. Its presence
was, however, transient, and appeared to be not associated with
structural changes in the kidneys.[38]
[Footnote 38: _Berliner klin. Wochenschrift_, 1876, No. 28.]
Fatty infiltration and fatty degeneration of the kidneys occur in
chronic alcoholism, the former as part of the general fat
accumulation, the latter as a result of the general nutritive
disturbances.
Amyloid degeneration is rare, and can in no case be ascribed to the
direct action of alcohol.
Griesinger saw excessive diabetes insipidus follow a prolonged and
severe attack of acute alcoholism in a man twenty-eight years old, and
terminate fatally in the course of four months. Ebstein attributes the
polyuria of acute alcoholism to lesions of the brain.
Glycosuria is rare among drunkards.
The Bladder.—Catarrh of the bladder is not rare in chronic alcoholism,
especially in that form originating from excesses in malt liquors.
This condition, however, scarcely occurs with sufficient frequency to
be regarded as in any sense a symptom of alcoholism.
The Genital Organs.—The subjects of alcoholism are especially prone to
sexual disorders of all kinds—a fact to be explained by the influence
of alcohol on the imagination, and especially upon the sexual
appetite, its debasing effect on the moral sense and upon the
judgment, and the indifference to the consequences of exposure which
it begets. In the later stages of chronic alcoholism sexual power is
apt to be greatly enfeebled or wholly lost. This condition, which is
usually attended also by loss of sexual desire, is to be attributed to
the action of alcohol upon the nervous system rather than upon the
sexual organs themselves. It has nevertheless been established that
long-continued alcoholic excesses are apt to be followed by atrophy of
the testicles. Lancereaux has described a condition of these organs
resembling in all respects senile atrophy. On the other hand, Huss
attributed the impotence of alcoholic subjects to loss of nervous
tone. In the female, alcoholism produces disturbances of menstruation
and premature menopause. Alcoholic excesses are said also to produce a
liability to abortion, and Lancereaux has observed atrophy of the
ovaries in alcoholic subjects.
2. _Disorders of Special Structures_.—_a_. Disorders of the Locomotive
Apparatus.—The muscles at large, like the heart, are liable to fatty
infiltration and degeneration. Fatty infiltration, frequent at some
period in the course of the affection, is apt to be widespread. The
muscles are paler than normal, softer in consistence, and streaked
with fat. True fatty degeneration is less frequent, and apt to be
localized. Here the muscular fibres lose their striation, and present
within the myolemma minute fatty deposits in the form of granules.
This change is accompanied by atrophy. The symptoms consist in
feebleness and difficulty in movement and in locomotion.
Changes in the bones, notably enlargement of and increase in the
contents of the medullary canal in the long bones, and arthropathies
of various kinds, have been observed in alcoholic subjects.
{615} _b_. Disorders of the Skin.—Alcohol is a sudorific, and is
largely eliminated by the skin. This effect is purely physiological;
therefore the moderate and occasional use of alcohol exerts an
influence rather favorable than otherwise upon the tegumentary
structures, but in repeated excesses it gives rise to more or less
cutaneous irritation. The skin, partly for this reason, and partly
because it shares in the general disturbance of nutrition, becomes
dry, harsh, and scaly; after a time the face, and especially the nose
and neighboring parts, assumes in many instances a violaceous hue, the
minute superficial cutaneous veins are enlarged, and acne is common.
The resulting appearance is almost characteristic of the habits of the
individual. Alcoholic subjects frequently suffer from pruritis,
urticaria, and eczema. In certain cases the skin, instead of being dry
and harsh, is soft and unctuous, and in others, especially in the more
advanced cases, it becomes slightly yellow or earthy in hue. Owing in
part to changes in the nutrition, and in part to vascular dilatation,
the skin of the extremities is not rarely mottled and cyanotic. In
certain forms of alcoholism of the nervous system, and particularly in
alcoholic paralysis, in which we have to do with multiple peripheral
neuritis, the skin of the affected parts, especially that overlying
the atrophied muscles, becomes, in consequence of trophic changes,
dusky in color and hard, smooth, and glossy. It has been stated that
chronic alcoholism is a cause of pellagra, and numerous observations
have been advanced in support of this view (Hardy). The excessive
rarity of this condition in countries in which the abuse of alcohol is
most common renders it probable that the occasional association of
these affections is accidental rather than causal. Chronic alcoholism
predisposes to gangrene of the skin and to bed-sores; slight wounds
readily inflame and are slow to heal; alcoholic subjects are
especially predisposed to erysipelas, while the enfeeblement of the
circulation and the lowered tone in the later stages of chronic
alcoholism often result in œdema of the inferior extremities.
3. _General Disorders_.—In addition to the various local disorders
thus far described, the prolonged excessive indulgence in alcohol
leads to profound disturbances of the processes of nutrition, which
are manifested in alterations in the blood, in excessive accumulation
of fat, and in a well-marked cachexia.