Chapter M: M——, was a stout Irish woman about forty years of age. She had (8)

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.

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 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.

_a_. The Blood.—The alterations in the blood, although sufficiently manifest in disorders of nutrition, have not yet been studied with satisfactory results. In chronic alcoholism the proportion of water is increased, while that of fibrin is diminished. After death the blood remains fluid. The red globules are diminished in number. The blood also contains free fat, to which it owes its pale, opalescent, and sometimes almost milky hue. The presence of fat has been demonstrated after the injection of alcohol into the veins of animals.

_b_. Obesity.—Fat-infiltration and fat-accumulation must be regarded as among the most characteristic disturbances produced by alcohol. Fat is abundantly stored up in the subcutaneous tissues. The anterior abdominal wall is especially liable to its accumulation. The heart, kidneys, omentum, and mesenteries are also not infrequently the seat of abnormally large accumulations of fat. Fat also collects in the muscles and in the intermuscular planes, but to a less extent. Obesity is not, however, so frequent in the advanced stages of alcoholism as it is while the subject {616} has not yet lost the appearance of health, and in a large proportion of the individuals it does not manifest itself at all. It appears to depend largely upon the character of the drink, and is especially frequent among those addicted to excesses in beer. It is less common among wine-drinkers, and relatively infrequent and of moderate degree in those who confine themselves to spirits. A sedentary life, and perhaps also an hereditary tendency, exerts an important influence upon the development of obesity in alcoholism.

_c_. Alcoholic Cachexia.—The action of alcohol in excessive amounts upon the nutrition of the body at large, and in particular upon the nutrition of the nervous system, is radically unfavorable. This unfavorable influence manifests itself from the beginning, while the subject yet presents the appearance of health, and long before the occurrence of either the symptoms or physical signs of organic disease. The powers of resistance to unfavorable influences of all kinds are diminished; the ability to endure hardships, privations, and fatigue is lessened; sickness and injuries are badly borne; complications are frequent and grave; and convalescence is apt to be tardy and insecure. It is among the more striking peculiarities of the alcoholic subject that blood-losses are badly borne and slowly repaired. It is this want of tone, often latent for a long time under ordinary circumstances, which unfits those addicted to alcohol for Arctic and exploring expeditions and for military and scientific enterprises involving prolonged hardship and exposure. In the course of time disorders of the digestion, of hæmatosis, of circulation, increase the difficulty and render it more apparent. The fat now rapidly diminishes; anæmia develops; the complexion becomes dull, earthy, or slightly jaundiced, the tissues flabby. Then follow diarrhœa, hemorrhages from mucous surfaces, serous effusions, visceral congestions of high degree, hypostasis, œdema, and progressive deterioration of all the powers alike of the body and the mind until the dyscrasia is complete.

The subjects of chronic alcoholism are especially prone to affections of the respiratory tract and to the infectious diseases. They furnish, as a rule, the earliest victims in epidemics. They not rarely die of pneumonia. They develop troublesome delirium in simple maladies, and in all acute affections the prognosis is unfavorable as compared with that in persons of sober habits. As Clouston well says, “The whole organism suffers sanative and mental lowering, alteration of functions and of energizing.”

_B_. DERANGEMENTS OF THE NERVOUS SYSTEM: CEREBRO-SPINAL DISORDERS.—The disorders of the central nervous system in chronic alcoholism are even more numerous and more important than those already described. Many transient and permanent disturbances of function occur without anatomical lesions recognizable by existing methods of examination; many others are associated with readily-discoverable changes of structure. These changes are encountered in the blood-vessels, the meninges, the substance of the cerebro-spinal axis, and in the peripheral nerves. Much as they differ in appearance and in their clinical manifestations, they may all be referred to three processes: (_a_) congestion and inflammation; (_b_) sclerosis; and (_c_) stentosis.

1. _Cerebral Disorders_.—The Cranium.—The bones of the skull are often thicker and more dense than normal. This change implicates the {617} diploë and the outer and inner tables. The last is then deeply channelled for the blood-vessels and deeply indented for the Pacchionian bodies, which are commonly hypertrophied.

The Vessels.—Disturbances of the cerebral circulation are among the earliest and most important symptoms. Due primarily to the increased action of the heart and vaso-motor dilatation of the blood-vessels excited by repeated large amounts of alcohol, and secondarily to permanent enlargement of the vessels in consequence of fatty or atheromatous degeneration of their walls, some degree of active or passive congestion is almost always present. It is probable also that in consequence of irregular and complex disturbances of the circulation secondary localized ischæmia occurs. Lentz states that anæmia is more common in the cerebral substance than in the membranes.

The capillaries are usually much altered—sometimes uniformly dilated to a considerable extent, sometimes forming capillary aneurisms. They are more sinuous than normal, their walls show evidences of fatty degeneration, and they sometimes contain minute thrombi. Extravasated blood, in the form of circumscribed collections, of diffuse layers, or finally of capillary hemorrhages, also occurs. These collections are sometimes free, sometimes encysted.

The Meninges.—The dura mater is congested; occasionally it shows more or less extensive areas of inflammation with exudation of lymph. Purulent exudation in the absence of traumatism is rare. The lymph may be deposited in the form of patches of varying extent, or it may form more or less extensive false membranes. These accumulations are of variable, often considerable, thickness, and constitute the condition described as pachymeningitis hæmorrhagica interna, or, from the large amount of blood which they contain, hæmatoma of the cerebral meninges. They occupy the convexity of the brain, and are developed upon the inner surface of the dura; they are usually nearly symmetrical in outline, but of different thickness upon the two sides. They consist of superimposed layers of lymph, between which, or within the substance of which, are more or less extensive blood-extravasations, either fluid, coagulated, or undergoing resorption. More frequently the exudation consists of mere shreds of lymph within the cavity of the arachnoid.

The arachnoid is almost invariably altered. Upon the convex surface of the hemispheres, especially along the median fissure, it is thickened and opaque. This condition may be uniform or distributed in patches, and is apt to follow the line of the blood-vessels.

The pia mater is congested, often œdematous, not rarely the seat of blood-effusions of greater or less extent.

The cerebro-spinal fluid is usually more abundant than normal, of a deeper color, cloudy, sometimes tinged with the coloring matter of the blood.

The Brain.—The intimate lesions of the substance of the brain are not yet known. The volume of the encephalon, as a rule, undergoes no change. Occasionally it appears to be swollen, and protrudes with some degree of force through the incision first made in the membranes. More commonly, the brain is throughout or in certain parts atrophied or shrivelled, its convolutions flattened, its surface retracted. This is sometimes the result of the pressure of collections of hemorrhagic or inflammatory products.

{618} The consistence of the cerebral mass is sometimes increased; it becomes harder, more resistant to pressure, and preserves its form when removed from the cranium better than the normal brain. This condition may be present throughout the brain or it may be localized. In the latter case it is usually due to patches of sclerosis. Softening in more or less extensive areas may occur in the advanced stages of the more severe forms of chronic alcoholism. It is found chiefly in the gray substance, where the vessels are more numerous, especially in the cortex and central ganglia. In this as in other affections cerebral softening is the result of obstruction of the circulation in consequence of atheroma, thrombosis, or other change in the arteries. It varies from simple diminution in consistency to diffluence.

The nervous substance of the brain doubtless undergoes changes proportionate to the degree and duration of its exposure to an alcohol-charged blood. What these changes are has not yet been fully determined. The nerve-cells of the cortex have been found rounded and contracted, so that instead of being surrounded by a small lymph-space they seem to be lying in large cavities, and so granular that the nucleus can hardly be made out. Slight increase in the number of the small round cells in the cortex and in the adjoining parts of the white matter has also been observed (Hun). These changes are not, however, constant. Not only has the microscopical morbid anatomy of the lesions of nerve-substance peculiar to chronic alcoholism not yet been worked out, but even macroscopic changes adequate to account for symptoms that were during life serious, persistent, and apparently referable to well-defined lesions, are sometimes absent altogether.

It is important to distinguish the disorders due to the direct action of alcohol, which are often functional or dependent upon lesions too subtle for recognition, from those which are secondary and dependent for the most part upon coarser changes of structure.

In consequence of hyperæmia of the brain and its membranes there not infrequently occur a sense of confusion or dulness, increasing to headache, which may become almost unbearable, mental disturbances of the most varied character, disorders of movement and sensation, and disorders of the special senses.

Cerebral hemorrhage, to which the subjects of chronic alcoholism are, in consequence of the vascular lesions already described, peculiarly prone, manifests itself by the usual primary and secondary phenomena. Meningeal hemorrhage, save in the form of hæmatoma, is rare except in the advanced stages of paretic dementia.

The blood in alcoholic dyscrasia undergoes changes which favor its transudation through the walls of the vessels; hence a tendency to œdema and to accumulations in serous sacs. This tendency implicates the structures of the nervous system in common with the organism at large. The ventricles of the brain become distended with fluid, and the brain-substance itself and the meninges not rarely become œdematous in the last stage of chronic alcoholism, in consequence of grave disturbances of the circulation or as complications of affections of the lungs, heart, or kidneys. These conditions are attended by mental obscuration, somnolence alternating with sleeplessness, delirium, maniacal paroxysms, impairment {619} of muscular power, of general and special sensibility, impaired reflexes, inability to speak, deepening stupor, and death.

2. _Spinal Disorders_.—Lesions of the spinal cord or its membranes have been rarely discovered. When present they have been invariably associated with similar or corresponding lesions of the brain or its envelopes. Leyden[39] states that not only do the cerebral meninges present inflammatory changes in chronic alcoholism, but the meninges of the cord are sometimes found in an analogous condition; that pachymeningitis hæmorrhagica interna spinalis has also been observed, as well as other forms of spinal meningitis, with thickening and discoloration of the pia and dura; and that œdema of the pia has been especially noted. While anatomical lesions of the cord are less frequent than lesions of the brain, nutritive and functional disturbances, as manifested in the general symptomatology, are quite as common in one as in the other.

[Footnote 39: _Klinik des Rückenmarkskrankheiten_.]

3. _Disorders of the Peripheral Nerves_.—Magnus Huss found no change in the peripheral nerves in five cases in which they were carefully examined. Lancereaux discovered degenerative changes in the peripheral filaments in alcoholic paralysis. Leudet found hypertrophy of the neurilemma and alterations in the cubital nerve in an individual suffering from chronic alcoholism in whom this nerve was paralyzed. Dejerine[40] observed in two fatal cases of alcoholic paralysis neuritis of peripheral nerves with integrity of the nerve-roots, the spinal ganglia, and the cord. In one of Dreschfeld's cases of alcoholic paralysis,[41] in which the cord was found perfectly normal, the “sciatic appeared thin and grayish, and was surrounded by a great deal of adipose tissue. Vertical sections showed, when treated with perosmic acid and stained afterward with picro-carmine, a moniliform appearance of the nerve-tubes, due to breaking up of the myelin; the nuclei were increased, and there was also some interstitial cell-infiltration. Transverse sections showed in some few places an increase in the diameter of the axis-cylinder, and again the interstitial infiltration.”

[Footnote 40: _Archives de Physiologie nerv. et patholog._, No. 2, 1884.]

[Footnote 41: _Brain_, Jan., 1886.]

Disorders of General Sensibility.—Disorders of general sensibility are among the earliest of the nervous phenomena of chronic alcoholism. They occur in the following order: hyperæsthesia, dysæsthesia, and anæsthesia. Disturbances of sensibility manifest themselves, quite independently of hallucinations, as sensations of malaise, of discomfort, of chilliness, of cramps, or of abnormal warmth or cold. Sometimes they amount merely to momentary discomfort, at other times to extreme pain. They are usually limited, often to the feet and legs, sometimes to the hands and arms; again, they are experienced in the trunk, and especially in the back. They are most common during the evening; less frequently they are induced by the warmth of the bed; and, again, they are experienced on rising. They are apt to be associated with occipital or frontal headache.

Among the most frequent nervous phenomena of chronic alcoholism are disturbances of sleep. Sleep is light, uneasy, and disturbed, difficult to obtain, troubled with dreams, and unrefreshing. More or less complete insomnia is by no means rare. It is more apt to occur, however, after acute exacerbations of alcoholism than in the ordinary chronic condition.

{620} Hyperæsthesia manifests itself as an increased sensibility to pain, to mere contact, to temperature, and in an exaggeration of the muscular sense. Two general forms may be distinguished—the superficial and deep. The former usually manifests itself by an exaggerated sensibility of the skin, especially along the course of the superficial nerves and at their points of emergence from the deeper structures. The latter consists in a more or less intense sensation of pain, often diffuse, sometimes almost unbearable, and associated with a sensation of heat or cold, which is most commonly experienced in the lower extremities. It is often referred by the patient to the deeper muscles or to the bones and joints, and is increased by movement or pressure.

Anæsthesia is a much more common occurrence. It is usually developed during the later period of chronic alcoholism, and may implicate the skin, the mucous tissues, or the deeper structures. It presents all degrees from mere impairment to absolute loss of sensation. In the latter case, contact, pain, temperature, and electrical stimulation equally fail to excite sensation. In the deep anæsthesia of alcoholism pressure and electro-muscular sensibility are alike impaired. The muscular sense is also enfeebled or abolished. The regions which are the seat of anæsthesia are, as a rule, of a lower temperature than those in which sensation is normal. The anæsthesia may extend to the conjunctiva, and even to the cornea and to the mucous membrane of the mouth and throat. It has also been observed in the mucous membrane of the genitalia and at the verge of the anus.

Disorders of Motion.—Disorders of motion consist of tremor, subsultus, spasm, convulsions, muscular paresis, and palsies. Tremor is a very frequent phenomenon in chronic alcoholism. It consists generally of a series of rapid rhythmical movements. Sometimes the extent of the movement is increased and their rhythm irregular. They are then choreiform. The tremor may be continuous; much more frequently it only appears in the morning. The subject has then some difficulty in dressing himself, particularly in buttoning his clothing, in shaving himself, and in raising a cup to his lips. This symptom commonly ceases after the ingestion of a certain quantity of alcohol, only to return on the following morning or after a considerable period of abstinence. Voluntary movements intensify the tremor. It most commonly affects the upper extremities, next in frequency the muscles of the face, and finally the lower extremities. In rare cases it affects the muscles of the whole body. Alcoholic tremor affecting the hands and arms renders the subject awkward and interferes with his ability to work; affecting the lower extremities, it gives rise to an embarrassing, irregular gait; affecting the lips and tongue, it produces hesitation of speech or stammering, and when it is of a high degree articulation may be so imperfect that conversation is impossible; affecting the muscles of the eyes, it gives rise to nystagmus. Tremor is not infrequently associated with subsultus tendinum, spasmodic contractions, and cramps. These phenomena are usually localized, and affect by preference the muscles of the face and those of the lower extremities.

Loss of muscular power, which may pass, little by little, into complete palsy, also occurs. It is, however, neither constant nor proportionate to the gravity of the case in other respects. Whilst, as a rule, it is developed insidiously, it occasionally shows itself with suddenness. In the latter {621} case it is usually preceded by some acute complication, and may disappear as quickly as it came. At first it is a mere feebleness, which, beginning in the fingers, extends to the hands and arms. It may after a time manifest itself in the feet. More or less muscular paresis is invariably associated with the tremor above described.

Alcoholic Paralysis.—The earliest account of alcoholic paralysis is that of James Jackson,[42] who designated the disease, from its most prominent symptom, arthrodynia. He attributes it to ardent spirits, and chiefly observed it among women. “This arthrodynia comes on gradually. It commences with pain in the lower limbs, and especially in the feet, and afterward extends to the hands and arms. The hands may be affected first in some instances, but in all cases in the advanced stage of the disease the pain is more severe in the feet and hands than in the upper limbs. The pain is excruciating, and varies in degree at different times. It is accompanied by a distressing feeling of numbness. After the disease has continued a short time there take place some contraction of the fingers and toes and inability to use these parts freely. At length the hands and feet become nearly useless. The flexor muscles manifest, as in other diseases, greater power than the extensors, and the whole body diminishes in size, unless it be the abdomen; but the face does not exhibit the appearance of emaciation common to many visceral diseases. The diminution is especially observable in the feet and hands. At some time the skin of these parts acquires a peculiar appearance. The same appearance is noticed in a slighter degree in the skin of other parts. This appearance consists in great smoothness and shining, with a sort of fineness of the skin. The integument looks as if tight and stretched, without rugæ or wrinkles—somewhat as when adjacent parts are swollen. The skin is not discolored. In this disease there is not any effusion under the skin, and the character which it assumes arises from some change in the organ itself.”

[Footnote 42: _New England Journal of Medicine and Surgery_, vol. xi., 1822, “On a Peculiar Disease resulting from the Use of Ardent Spirits.”]

Since Jackson's day, Huss, Lancereaux, Leudet, and others have described various forms of paralysis due to alcohol. Wilks[43] under the term alcoholic paraplegia described a form of alcoholic paralysis of which he had seen numerous cases, especially in women addicted to alcoholic excesses. The symptoms are severe pain in the limbs, especially the lower ones, with wasting, numbness, anæsthesia, only slight power of movement or total inability to stand. The symptoms are not unlike those of ataxia. Wilks regarded the disease as due to degeneration of the cord and thickening of the membranes. Several of the cases terminated in recovery in a comparatively short time after the abrupt and complete withdrawal of alcohol. Since that time a number of cases have been reported by various observers.[44]

[Footnote 43: _Lancet_, 1872, vol. i. p. 320.]

[Footnote 44: See, in particular, Hun, _American Journal of the Medical Sciences_, April, 1885, “Alcoholic Paralysis.” This paper contains a valuable résumé of the reported cases up to that time. Consult also Dreschfeld, _Brain_, July, 1884, and January, 1886.]

Hun concludes that alcoholic paralysis may be regarded as a special form of disease with the following symptoms: “Neuralgic pains and paræsthesiæ of the legs, gradually extending to the upper extremities, and accompanied at first by hyperæsthesia, later by anæsthesia, and {622} in severe cases by retardation of the conduction of pain. Along with these symptoms appears muscular weakness, which steadily increases to an extreme degree of paralysis, and is accompanied by rapid atrophy and great sensibility of the muscles to pressure and to passive motion. Both the sensory and motor disturbances are symmetrically distributed. The paralysis attacks especially the extensor muscles. In addition to these motor and sensory symptoms, there is also a decided degree of ataxia. The tendon reflexes are abolished, and vaso-motor symptoms, as œdema, congestion, etc., are usually present. Symptoms of mental disturbance are always present in the form of loss of memory or transient delirium.”

Lesions of the cord are absent, but degenerative processes in the peripheral nerves have been discovered in a number of cases. The symptoms are those of multiple neuritis, and the essential lesions consist in degenerative changes in the peripheral nerve-fibres. The associated mental derangement, tremor, and ataxia have been ascribed to changes in the cerebral cortex.

Dreschfeld has divided the cases, according to the more prominent symptoms, into two clinical groups—alcoholic ataxia and alcoholic paralysis.

The ataxic form represents a milder type. The symptoms are lancinating and shooting pains in the lower extremities, sometimes in the upper, with areas of anæsthesia and retarded sensibility. The muscles are painful upon pressure, and atrophy may be moderate or absent altogether. Inco-ordination is marked. The tendon reflexes are absent. Shooting pains down the legs to the toes of a paroxysmal character, and followed by a sense of numbness, also occur. Eye symptoms are wanting.

The paralytic form is usually associated with atrophy, affecting chiefly the extensors of the fingers and toes. The paralysis and atrophy in some cases come on acutely, in others more slowly. When the patients come under observation they are usually unable to stand or walk, and it is therefore not easy to make out whether or not the paralytic stage has been preceded by a stage of ataxia. As the sensory phenomena in these cases are the same as in the first group, it is probable that pseudo-ataxic symptoms have preceded the slowly oncoming paralysis. Paralysis and atrophy of the extensors of the fingers and toes, with paresis of the other muscles, are associated with the sensory phenomena above described. Tendon reflexes are absent; the superficial reflexes are much diminished. Recovery takes place in a considerable proportion of the cases upon the withdrawal of alcohol. The atrophy and paralysis pass away altogether, the tendon reflexes are restored, and the disturbances of sensation disappear. In the greater number of these cases persistent delusions are present.