Percy23injected by means of an œsophageal tube 90 grammes of absolute alcohol into the stomach of a dog. Death followed in the course of eight hours in consequence of violent gastro-intestinal inflammation with ulceration. Dujardin-Beaumetz and Andigie found the gastric and intestinal mucous membrane of dogs poisoned by alcohol, red, deeply injected, and “presenting at certain points a black coloration due to effused blood.” This fact they regard as worthy of note, because in their experiments the toxic agent was introduced, not by the mouth, but hypodermically, and they explain it by the supposition—which appears to me warrantable—that it is due to elimination by the mucous glands. Hence the congestion, softening, and hemorrhage.24These observers also found that the symptoms were more acute and the lesions more marked when poisoning was caused by propyl, butyl, or amyl alcohol than when it was produced by ethyl alcohol.
23An Experimental Inquiry concerning the Presence of Alcohol in the Ventricles of the Brain after Poisoning by that Liquid, together with Experiments illustrative of the Physiological Effects of Alcohol, London, 1839.
24Chatin and Gublier have emphasized the fact that certain poisons introduced by intravenous injection or by absorption through the respiratory tract are eliminated by the intestines, with the production of the same local symptoms as when administered by the mouth (Bulletin de l'Académie de Médecine, Séance du 6 Novembre, 1877).
2.Acute Narcotic Poisoning.—Much more common are the cases in which death is rapidly produced by excessive doses of ordinary diluted alcohol taken at once or rapidly repeated. This happens under various circumstances, as when a drunkard avails himself of some favorable opportunity to gratify to the full a bestial appetite, or upon a wager drinks a number of glasses of spirits in quick succession or a given quantity down, or when a man already drunk is plied by his companions for pure deviltry. Suicide by this means is, in the ordinary sense of the term, rare, and murder still more so. The latter crime has, as a rule, been committed upon infants and children. Blyth25estimates the fatal dose of absolute alcohol, diluted in the form of ordinary whiskey, gin, etc., at from one to two fluidounces for any child below the age of ten or twelve years, and at from two and a half to five ounces for an adult. In the instance recorded by Maschka26two children, aged respectively nine and eight years, took partly by persuasion, afterward by force, about one-eighth of a pint of spirits of 67 per cent. strength—about 1.7 ounces of absolute alcohol. Both vomited somewhat, then lay down. Stertorous breathing at once came on, and they quickly died. Taylor relates a case in which a quantity of brandy representing about two fluidounces of absolute alcohol produced death in a child seven years old.
25Poisons, their Effects and Detection, Am. ed., New York, 1885.
26Cited by Blyth.
The symptoms are uniformly the same. The period of excitement is transient or absent altogether; occasionally the patient falls at once to the ground while in the act of drinking or immediately thereafter; complete coma, interrupted by shuddering convulsions, may terminate in the course of a short time in death. If the fatal issue be delayed, there are vomiting and involuntary discharges; the respiration becomes slow, embarrassed, stertorous; the heart's action is feeble and irregular, the pulse almost or wholly imperceptible; the temperature rapidly falls several degrees: 90° F. has been observed. The pupils are dilated; insensibility and muscular resolution are complete. The face is bloated, cyanotic; thesurface bathed in a clammy sweat; the mucous membrane of the mouth often swollen and blanched. Vomiting is usual, but not constant, and there is occasionally thin mucous diarrhœa, the stools being mixed with blood. If the patient survives any considerable length of time, acute superficial gangrene of the parts most exposed to pressure is liable to take place. Recovery is rare; its possibility is, however, increased in proportion as the subject is of vigorous constitution, previous sound health, beyond the period of childhood, not yet approaching that of physiological decadence, and as treatment is early instituted and carried out with judgment.
The diagnosis is difficult, almost impossible, in the absence of witnesses: it is rendered still more obscure by the fact that this, as other forms of alcoholic coma, may be complicated by cerebral or meningeal hemorrhage and by cerebral congestion, in themselves fatal—lesions the onset of which may have been the cause of mental aberration leading to the commission of impulsive alcoholic excesses.
The prognosis, in the highest degree unfavorable in all cases, is rendered yet more so by the occurrence of intense cerebral and pulmonary congestions.
The lesions found post-mortem are those of acute alcoholism, already described. As this form of alcoholic poisoning frequently occurs in the subjects of chronic alcoholism, the lesions of that condition are often encountered, and must be distinguished from those due to the lethal dose. Nor must we overlook the fact that in the action of alcohol just described we have to do with a process differing from ordinary acute alcoholism in degree rather than in kind—a consideration which tends to simplify our notions of the pathology of alcoholism in general.
The prolonged abuse of alcohol brings about a series of changes which affect alike the organism at large and its various structures. The changes thus brought to pass are of the most varied kind, and depend upon individual differences too manifold and complex for enumeration and classification. Among the more important of these individual peculiarities are those which relate to temperament, constitution, hereditary predisposition, occupation, social position, personal habits, tendency to or already-existing disease of particular organs and systems, and the like. The degree of the pathological change is determined by the strength and quantity of alcohol consumed and the duration of habitual excess. The human body is capable of adapting itself to the habitual consumption of large quantities of alcohol, just as to other directly acting agents of an injurious nature, such as foul air, bad drinking-water, and unwholesome food, or even to the action of substances dangerous to life, as opium or arsenic, and yet presenting for a considerable time the appearance at least of health. Degeneration of the tissues of the body and disorders of its functions are nevertheless surely produced. These alterations are not the less dangerous to health and life because they are insidious and remain for a time latent. Furthermore, like the habit of which they are begotten, they are progressive, and sooner or later declare themselves in open disease.
The condition, whether latent or manifest, that is produced by prolonged habitual alcoholic excess is designated chronic alcoholism.27
27The writer, although fully aware of its imperfections, regards the above definition of the term as more in accordance with the present state of our knowledge of the subject, and therefore more useful, than any other that he has been able to find. It is scarcely necessary to repeat here that the restriction of the term chronic alcoholism to accidental or occasional manifestations of a permanent state is misleading and unscientific. The same criticism is applicable to the attempt that has been made to establish this condition as a substantive disease, chronic, progressive, and characterized anatomically by inflammatory, sclerotic, and steatogenous processes.
The symptoms of this condition, when fully established, differ within wide ranges in kind and degree. They are the manifestations of derangements of the viscera, of the nervous system, and of the mind. Varying among themselves according as the stress of the pathological action has fallen upon one organ or another, forming combinations at once curious and inexplicable, developing quietly, without event, almost imperceptibly at one time, breaking into the most furious paroxysms at another, they present for our study perhaps the most complex of chronic morbid conditions. The chronic alcoholism which is latent is not, therefore, always without symptoms. They are, however, often slight and escape observation, or when manifest they are not infrequently ascribed to other causes; or, again, their etiological relations being concealed or overlooked, they are exceedingly obscure and puzzling. This is especially the case in the chronic alcoholism produced by the secret tippling of otherwise respectable persons, and especially women.
To facilitate description, we shall consider the derangements of the viscera, the nervous system, and the mind in regular order, according to the scheme onp. 574. But the reader will observe that whatever may be the prominence of particular symptoms or groups of symptoms in any given case, all parts of the organism are involved, and that there is no such thing as chronic alcoholism restricted to any particular viscus or group of viscera, to the nervous system, or to the mind.
A. VISCERALDERANGEMENTS.—There is nothing specific in the lesions of chronic alcoholism. The chronic hyperæmia, steatosis, and sclerosis induced by alcoholic excesses differ in no respect from those conditions brought about by other causes. That which is specific is the evolution of a series of morbid changes in the different structures of the body under the influence of a common and continuously acting cause. The digestive system is affected, as a rule, long before the vascular or the nervous system.
1.Local Disorders.—a. Disorders of the Digestive System.—The Mouth and Throat.—The action of insufficiently diluted alcohol upon the mucous tissues is that of an irritant. The habitual repetition of this action causes subacute or chronic catarrhal inflammation. The condition of the tongue varies with that of the stomach. The mouth in acute alcoholism is apt to be pasty and foul, the tongue slightly swollen and coated with a more or less thick yellow fur; there is often also an increase of saliva; in chronic alcoholism the tongue is usually small, sometimes red, sometimes pale, often smooth from atrophy of the papillæ, not rarely deeply fissured. In a word, the condition of this organ is that seen in the various forms of subacute or chronic gastritis. The salivary secretion is often notably diminished, the sense of taste impaired. Relaxation of the throat anduvula and granular pharyngitis are common. Those who, whilst leading a sedentary life, are inclined to the pleasures of the table and a free indulgence in spirituous liquors often suffer from these affections. Mackenzie28states that the worst cases of chronic catarrh of the throat generally arise from the habitual abuse of the stronger forms of alcohol. The associated influence of tobacco in the causation of this group of affections is not to be disregarded.
28Diseases of the Pharynx, Larynx, and Trachea, 1880.
Lancereaux encountered ulceration of the œsophagus, and Bergeret a case of narrowing of that organ, in chronic alcoholism.29
29Peeters regards it as probable that the connective-tissue hyperplasia and resulting stenosis seen in the stomach as a result of the action of alcohol may also occur in the œsophagus.
The Stomach.—In addition to functional dyspepsia, which is scarcely ever absent in chronic alcoholism, all forms of gastritis, from simple erythematous inflammation of the mucous membrane to sclerosis and suppurative inflammation of the stomach, are encountered. Armor30assigns to the habit of spirit-drinking, especially to the habit of taking alcohol undiluted on an empty stomach, a high place among the causes of indigestion. He regards this habit as a prominent factor in the production of chronic gastric catarrh—a condition very frequently present in indigestion. This observer also regards the excessive use of alcohol as the most frequent among the direct exciting causes of gastric inflammation in this country, exclusive of acid or corrosive poisons. Next to errors in diet as a cause of chronic gastritis he places the immoderate use of alcohol, especially by persons whose general health and digestive powers are below a healthy standard. The primary lesions are vascular dilatation and hyperæmia. The mucous membrane is discolored, red or bluish, in scattered patches of varying size, with occasional ecchymoses of a bluish hue or spots of pigmentation. These patches occupy more commonly the region of the cardia and the lesser curvature. Vascular injection is conspicuous; the veins are dilated, tortuous; the mucous glands hypertrophied; the surface covered with thick, ropy, acid-smelling mucus. After a time permanent changes in the mucous membrane are set up. It undergoes atrophy or softening; or, again, it becomes hardened, thickened, and contracted, its rugæ more prominent, its surface mammilated—sclerosis. Grayish-brown pigmentation, the remains of former blood-extravasations, is seen at many points. Minute retention-cysts are formed in consequence of the occlusion of the ducts of certain glands. The submucous connective tissue and the muscular coat occasionally undergo, in consequence of prolonged gastritis, local hypertrophy.
30See thisSystem of Medicine, Vol. II. pp. 446, 464, 470.
Acute suppurative inflammation of the stomach, with purulent infiltration of, or the formation of abscesses in, the submucous tissue, has been met with in drunkards. It is extremely rare, and results from the violent irritant action of large doses of strong alcohol in subjects debilitated by previous excesses.
Gastric ulcer is much more common. The abuse of alcohol is regarded as an indirect cause of this lesion by the majority of writers. In the present state of knowledge alcohol as usually taken can scarcely be regarded as a direct cause of ulceration. Nevertheless, gastric ulcer is relativelycommon in alcoholic subjects. Leudet31found gastric ulcer in 8 of 26 necropsies of drunkards. Baer and Lentz also regard the abuse of alcohol as a very common cause of ulceration. The ulcers are usually superficial, occupy by preference the neighborhood of the cardia and the lesser curvature, and are apt to be multiple. In these respects they differ from simple gastric ulcer. The latter lesion is also probably as frequent, if indeed not more frequent, in individuals dying of chronic alcoholism than in others.
31Clinique médicale de l'Hôtel Dieu à Rouen, 1874.
The view formerly entertained that alcohol was an important cause of cancer of the stomach has been shown by Kubik, Magnus, Huss, Engel, and others to be untenable. Carcinoma ventriculi is rarely associated with chronic alcoholism.
The dimensions of the stomach are rarely normal. Dilatation is usually present in the early stages, and in beer-drinkers throughout; in the advanced course of alcoholism due to spirit-drinking the organ undergoes, in consequence of changes secondary to prolonged inflammation, more or less contraction, which is in many cases irregular.
Dyspeptic symptoms are common: the appetite is variable, irregular, and at length wholly lost. There is especially distaste for food in the morning. This, together with the disordered state of the secretions of the mouth and a feeling of nervous depression on rising, leads to the disastrous habit of taking spirits early in the day. Gastric digestion is performed with difficulty; it is accompanied by sensations of distension and weight, by flatulence and acid eructations. Heartburn is a common symptom. The drunkard is not rarely tormented by an uneasy craving or sense of emptiness in the region of the stomach, which he temporarily allays by nips and pick-me-ups and morsels of highly-seasoned foods at odd times, with the result of still further damage to his digestion and the complete loss of appetite for wholesome food at regular hours. In the course of time the characteristic morning sickness of drunkards is established. On arising there is nausea, accompanied by vomiting—sometimes without effort or pain, at others attended by distressing retching and gagging. The matter vomited consists usually of viscid mucus, at first transparent, then flaky, and at length, if the efforts be violent, of a green or yellow color from the admixture of bile. These symptoms ordinarily do not recur until the following day. In other cases vomiting is more frequent, recurring at irregular periods during the day, and not uncommonly an hour or two after the ingestion of food. When gastric ulcer is present, portions of the vomited matter are often dark and grumous like coffee-grounds or the settlings of beef-tea, and are found upon microscopic examination to contain blood-corpuscles. Actual hæmatemesis may also occur under these circumstances, and be repeated from time to time. The quantity of blood thrown up is frequently small; at times, however, it is excessive, and occasionally so great as to cause death.
Common as are the evidences of gastric disturbance in chronic alcoholism, they are far from being constant, and it is worthy of note that in proportion to the number of the cases serious gastric affections are, except in the later stages, relatively infrequent.
The Intestines.—Lesions of the small intestine due to alcoholism areextremely 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 Lancereaux32to 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.
32Dictionnaire 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 isfirm, 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 lessdistinct 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
33Consult thisSystem 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 greaternumber of observers coincide. But that alcohol is not the sole cause of chronic interstitial hepatitis has been abundantly established. As long ago as 1868, Anstie34wrote 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.” Formad35states 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.
34A System of Medicine, Reynolds, vol. ii. p. 74.
35Proceedings 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,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 issecreted 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.
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.
Pneumonia.—Habitual alcohol-drinkers are far more liable to pneumonia 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 prognosisis 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.