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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.24 These 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.
23 An 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.

24 Chatin 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. Blyth25 estimates 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 Maschka26 two 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.
25 Poisons, their Effects and Detection, Am. ed., New York, 1885.

26 Cited 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; the
surface 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.

II. Chronic Alcoholism.

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
27 The 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 on p. 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. VISCERAL DERANGEMENTS.—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 and uvula 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.
Mackenzie28 states 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.
28 Diseases 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
29 Peeters 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.
Armor30 assigns 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.
30 See this System 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 relatively common in alcoholic subjects. Leudet31
found 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.
31 Clinique 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 are

extremely rare. Even when simple or ulcerative inflammation of the
stomach is localized at, or extends to, the pylorus, it rarely passes
any great distance into the gut. The large intestine is, on the
contrary, frequently the seat of chronic inflammatory processes. Here
we find vascular engorgement, patches of pigmentation, localized
thickening of the mucous and submucous tissues, enlargement of
the solitary glands, and an excessive secretion of viscid mucus. The
tendency to permanent vascular dilatation, which is a characteristic
result of alcoholic habits, constitutes a powerful predisposing
influence in the causation of hemorrhoids, which are common.
Alcohol acts directly upon the hemorrhoidal plexus of veins, and
indirectly by causing permanent congestions of more or less intensity
in the greater number of the abdominal viscera. When a prolonged
course of excesses in alcohol has led to chronic congestion with
hypertrophy, cirrhosis, or other structural change in the liver which is
capable of causing permanent mechanical obstruction of the portal
circulation, hemorrhoids constitute a very common affection in the
group of morbid entities secondary to these conditions.

The symptoms of intestinal derangement are in the beginning, as a

rule, slight and occasional. They consist of uneasy sensations or
colicky pains in the abdomen, a feeling of fulness with or without
tympany, and constipation alternating with diarrhœa: in a word, they
are the symptoms of acute or subacute intestinal indigestion
terminating in an attack of intestinal catarrh. Attacks of this kind
repeat themselves in a considerable proportion of the cases with
variable but increasing frequency, until at length the conditions of
which they are the expression become permanent, and the patient
suffers, among other distressing symptoms hereafter to be
described, from chronic diarrhœa. The stools are now of the most
variable character—occasionally bilious, sometimes containing small
dark scybalous masses, rarely formed, but usually containing more
or less abnormal mucus, too much fluid, and traces of blood. Indeed,
at this stage several causes—among which I may mention visceral
congestions, local inflammation of the intestinal mucous membrane,
dilatation of the hemorrhoidal veins, and structural changes in the
liver—conspire to determine blood toward the interior of the intestinal
tube. Traces of blood in the stools are therefore frequent, and actual
hemorrhage and the appearance of the dark, tarry, and altered blood
formerly described under the term melæna are by no means rare.
Colliquative diarrhœa and dysenteric attacks also occur, and at
length an intense enteritis with uncontrollable diarrhœa may end the
life of the patient. The conditions just described lead to rapid
emaciation, and contribute when present to the establishment of the
cachexia so marked in many cases of chronic alcoholism.

The Glands.—The salivary glands were found by Lancereaux32 to

have undergone softening, with granulo-fatty changes in their
epithelium. If such changes are among the usual effects of alcohol,
they are doubtless productive of alterations in the saliva, which
explain, in part at least, the dryness of the mouth so frequent among
drunkards.
32 Dictionnaire de Médecine, art. “Alcoholism.”

The pancreas is, as the result of interstitial inflammation, the seat of

similar changes. It is sometimes enlarged and softened, sometimes
atrophied, shrivelled, or cirrhotic. In the latter condition its
consistence is firm, its surface uneven, its color deep yellow, brown,
or pale. Hyperplasia of the interacinous connective tissue, with
subsequent contraction and atrophy and destruction of the glandular
tissue, characterizes the more chronic forms of pancreatitis, and the
organ is frequently the seat of scattered minute blood-
extravasations. I have already alluded to the enlargement of the
solitary glands which constitutes a feature of the condition of the
large intestine. The solitary glands and Peyer's patches of the small
intestine are rarely altered.
b. Disorders of the Liver.—Next in order to the stomach, the liver is
more directly exposed to the action of alcohol than any other viscus.
For this reason lesions of the liver are frequent and grave. It is
worthy of note, however, that in a small proportion of cases of
chronic alcoholism terminating fatally, with widespread evidences of
the destructive action of alcohol upon the other organs of the body,
the liver has been found, both in its macroscopic and microscopic
appearances, wholly normal. Absorbed by the gastric vessels,
alcohol passes directly, by way of the portal vein, into the
parenchyma of the liver, there giving rise to various disturbances, the
nature of which is determined by the tendencies of the individual on
the one hand, and on the other hand by the character of the alcohol
consumed. The danger of hepatic disease is in direct proportion to
the amount and the concentration of the alcohol habitually taken.
The steady drinkers of spirits of whatever kind, whether gin, brandy,
whiskey, or rum, present the largest proportion of diseases of the
liver. These affections are far less common among beer-drinkers,
and infrequent among wine-drinkers in wine-growing countries. In
this connection it is to be borne in mind that the presence of food in
the stomach retards to some degree the absorption of the alcohol
ingested, and to a certain extent constitutes a means of dilution.

Hepatic disorders due to alcohol may be arranged in two groups:

first, congestion and inflammation; second, fatty infiltration or
steatosis; and the inflammatory process may affect chiefly the
interstitial connective tissue on the one hand, giving rise to sclerosis,
or on the other the glandular substance, constituting a true
parenchymatous inflammation.

Congestion.—Congestion of the liver is an early lesion. It is brought

about by the direct irritant action of the alcohol itself in part, and in
part by the extension of inflammation from the stomach by
continuous mucous tracts. Its development is insidious.
Anatomically, the condition is characterized by vascular dilatation,
moderate tumefaction, slight increase in the consistence of the
organ; the surface is of a deeper red than normal; on section the
color is more intense and the oozing more abundant. At a later
period we have, as the result of chronic congestion, the cyanotic
liver; the color is brownish or violet, mottled, and on section the
surface is granular and the lobules distinct. The organ may now be
somewhat diminished in size, but it lacks the firmness of sclerosis
and the hobnail appearance due to the contraction of the interlobular
connective tissue in that condition.

The symptoms of congestion of the liver are the familiar symptoms of

gastro-hepatic catarrh, varying from the transient disturbance known
as biliousness to serious sickness, characterized by acute gastro-
intestinal phenomena, with vomiting, headache, and other
derangements of the nervous system—constipation, succeeded by
diarrhœa and by more or less distinct jaundice. The graver forms of
hepatic congestion are characterized by intense nausea, frequent
vomiting, pain and soreness in the epigastrium and right
hypogastrium, the physical signs of augmentation of the volume of
the liver, and well-marked yellow discoloration of the conjunctivæ
and skin. These attacks are usually afebrile: the pulse is slow; there
is considerable nervous and mental depression, a tendency to
vertigo, and occasional syncope. The urine is scanty and high-
colored, and presents the reactions of bile-pigment. Muscular tremor,
especially marked in the extremities and tongue, is often present, but
is to be attributed rather to the direct action of alcohol upon the
nervous system than to the condition of the liver.

Hepatitis.—There are two principal forms of inflammation of the liver

induced by alcohol—parenchymatous hepatitis and interstitial
hepatitis or sclerosis.

Several varieties of parenchymatous hepatitis have been described.

The anatomical discrimination of these varieties is attended with less
difficulty than their clinical diagnosis. One of the more serious is
diffused parenchymatous hepatitis or acute yellow atrophy. Alcoholic
excesses appear to constitute a predisposing influence to this grave
disorder (Lentz). In several cases prolonged and repeated excesses
have preceded its development. It is a true parenchymatous
inflammation, in which the glandular elements of the organ undergo
disintegration. The liver is diminished in volume in all its diameters. It
is of a uniform yellow color; its tissue is soft and friable; upon section
the hepatic cells are found to be replaced by a granular detritus
mingled with globules of coloring matter and a greasy, grayish-yellow
liquid exudation.

The symptoms of this affection are those of an acute

parenchymatous hepatitis of the gravest kind. In the early stages
there is intense jaundice, gastro-intestinal disturbance, and fever,
followed by speedy evidences of profound toxæmia. The patient
rapidly falls into the so-called typhoid state, with a tendency to coma.
The prognosis is, in the greater number or cases, a fatal one. So
close is the resemblance between acute yellow atrophy of the liver
and the phenomena of acute phosphorus-poisoning that by many
observers these two conditions are held to be identical.33
33 Consult this System of Medicine, Vol. II., article “Acute Yellow Atrophy of the Liver.”

There is little doubt that the view now generally held, that acute
yellow atrophy is due to the action of some unknown toxic principle,
is correct. Alcoholic excess must therefore be regarded merely in the
light of a predisposing influence. Acute yellow atrophy of the liver is
an exceedingly rare disease.

Suppurative Hepatitis.—Abscess of the liver is in temperate climates

infrequent as the direct result of alcoholic excess. It is frequently
ascribed, however, to improper alcoholic indulgence, especially
when combined with the eating of large quantities of improper food,
in tropical and subtropical climates. A form of hepatitis has been
described by Leudet under the head of chronic interstitial hepatitis
with atrophy. The symptoms are for the most part not very well
marked, and consist chiefly in general malnutrition, which may in fact
be dependent upon the associated gastric disturbance. Chronic
jaundice is usually present.

Interstitial Hepatitis.—Cirrhosis of the liver is in a large proportion of

cases directly attributable to alcoholic excess. In this view the
greater number of observers coincide. But that alcohol is not the sole
cause of chronic interstitial hepatitis has been abundantly
established. As long ago as 1868, Anstie34 wrote as follows:
“Considering the enormous quantities of spirituous liquors which are
drunk by many of the patients who apply for relief from the
consequences of chronic alcoholism, it would be natural for the
reader who holds the usual opinion as to the origin of cirrhosis of the
liver to expect that serious symptoms produced by the latter disorder
must often complicate cases of the former. The case is, however, far
otherwise in my own experience. Of the immense number of patients
in whom the nervous disorder has been clearly identified, I have only
seen thirteen cases in which the symptoms of cirrhotic disease
called for any special treatment, although a certain degree of
cirrhosis was doubtless present in many of the others; and I cannot
avoid the conclusion that some very powerful element over and
above the influence of alcoholic excess is needed to produce the
severe type of that disease.” Formad35 states as the result of his
investigations as coroner's physician of the city of Philadelphia that
cirrhosis of the liver is much less common in alcoholic subjects than
has been generally thought. My own experience during eleven years
as attending physician at the Philadelphia Hospital leads me to
endorse this opinion.
34 A System of Medicine, Reynolds, vol. ii. p. 74.

35 Proceedings of the Pathological Society of Philadelphia, Dec., 1885.

The anatomical lesions of chronic interstitial hepatitis consist

essentially in hyperplasia and hypertrophy of the connective tissue of
the organ. The progress of the affection is insidious and gradual;
some degree of enlargement, due in part to congestion and in part to
interstitial exudation, is followed by gradual diminution, with
retraction of the new connective tissue. When the connective-tissue
new formation is excessive, and retraction fails to take place, the
organ remains permanently enlarged (hypertrophic cirrhosis). During
the first period the volume of the organ is increased, its consistence
is more firm, and its surface is slightly granular. The second period is
characterized by induration, with diminution of the volume of the
organ and alteration of its form. The surface is uneven, deeply
granular, and usually of a mottled yellow color. The tissue is firm,
creaking under the knife. The connective tissue is enormously
increased, the glandular elements being proportionately atrophied.

The contracting connective tissue exercises at the same time a

compressing influence upon the hepatic cells and upon the vascular
supply throughout the organ; the radicals of the portal vein and the
branches of the hepatic artery are alike compressed, and in part
obliterated. The same is true of the bile-ducts. The functional activity
of the liver, at first diminished, is finally, to a considerable extent,
arrested. In consequence of these physical alterations in the
structure of the organ, the symptoms, which are at first insignificant,
become progressively more grave, until at length they constitute
complications of the most serious kind.

It can be no longer asserted that the interstitial hepatitis produced by

alcohol presents specific characters. It nevertheless differs in many
respects from that form due to valvular lesions of the heart, in which
there are induration, usually augmentation in the volume of the
organ, and persistent congestion. Congestion, in truth, is the chief
characteristic of the latter form, in which the surface is smooth and
glistening, of a deep brown or violet hue, and on section yellowish or
brown—a condition which has been well described under the term
cyanotic liver.

Sclerotic changes due to alcohol usually affect the organ throughout.

In this respect alcoholic cirrhosis differs from that form due to syphilis
in which the lesions are irregularly distributed.

The functional disturbances due to cirrhosis are, in the beginning,

obscure in themselves and masked by the concomitant gastric
derangement. Later, ascites constitutes the chief as well as the most
constant symptom. It is rarely altogether absent. Emaciation is also a
prominent symptom. No affection, not even diabetes or phthisis,
produces loss of flesh so rapid, so marked, and so significant as
cirrhosis of the liver in chronic alcoholism. Not only do the adipose
tissues waste, but the muscles themselves undergo rapid atrophy.
This fact is not surprising when we consider that the lesions of the
liver give rise to grave interference with every function of that organ.
In addition to the more common gastric symptoms, there is
constipation, not rarely alternating, without assignable cause, with
serous and sometimes bloody diarrhœa. Epigastric distress,
epistaxis, and hemorrhages from other mucous surfaces are
common, and are due in part to the disturbance of the general
circulation, and in part to alterations in the character of the blood
itself. The physical signs indicate in the early stages increase, and
afterward diminution, in the volume of the liver. Enlargement of the
superficial abdominal veins is a characteristic sign. Cirrhosis of the
liver is a grave affection, the course of which, at first slow, afterward
more rapid, almost invariably leads to a fatal termination.

Fatty Degeneration of the Liver.—Steatosis of the liver is of

extremely common occurrence in the advanced stages of
alcoholism. The anatomical changes consist in accumulation of fat-
globules in the liver-cells. French writers distinguish two varieties of
hepatic steatosis: first, that in which the cellular elements undergo no
change beyond that of an accumulation of fat-globules within their
substance; and second, that in which the liver-cells undergo an
actual disintegration, in the course of which fat-granules are formed,
and which is, as a matter of fact, a true fatty degeneration. The first
of these conditions is not incompatible with the functional integrity of
the organ, and is in many instances unattended by symptoms, being
discovered only upon examination after death. Its occurrence is to be
explained by the imperfect oxidation of waste products due to the
constant presence of alcohol in the blood, and by the habitual
excess of fat in the latter fluid. When fatty infiltration is of moderate
amount there are no changes in the volume or the contour of the
organ, and the condition is recognized only on microscopical
examination. At a later stage the organ becomes enlarged,
particularly in its antero-posterior diameter. The surface is now
smooth and glistening, its color yellow or reddish-yellow; upon
section it is anæmic, of a yellowish color, with patches of a reddish
hue, and its consistence is diminished. The indentation caused by
pressure of the finger persists. Under the microscope the hepatic
cells are enlarged, rounded, packed with fat-globules of varying size.
In some of the cells these globules coalesce and form more or less
extensive drops of fat. The bile which is 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.

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 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