A system of practical medicine. By American authors. Vol. 5

by Unknown

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—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.

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.