In the early sixties we at Cook County Hospital in Chicago, were impressed by the large number of
30-40 year old male patients with congestive heart disease in the absence of hypertension, myocarditis,
valvular or coronary heart disease. The history revealed heavy alcoholic intake of 80-100 grams daily in
up to 45% of the patients. However, only 1.6% had other organic changes compatible with alcoholism such
as cirrhosis of the liver. Histologically there were typical, albeit non-specific changes: in general
there was only moderate interstitial edema and fibrosis without inflammatory infiltrate. We assumed
these changes to be "alcoholic cardiopathy", which may be the result of a combination of etiological
factors, targeting the heart because of a possible genetic predisposition.
History of "Alcoholic Heart Disease"
When I came to the Institute of Pathology at the University of Munich , I discovered the work done
by Bollinger, a former director of this institute, and his coworkers. At the turn of the last century,
Bollinger (1886) was intrigued by the incidence of idiopathic cardiac hypertrophy, which was considered
to be the main cause of death in 4.6% and as contributory cause of death in 3.3% of 1000 autopsies. His
coworker Schmidbauer (1881) reported the incidence of this heart condition, which he mistakenly referred
to as myocarditis, in 14% of the males and 7% of the females in the hospital population. Bollinger's
predecessor Buhl had also described this condition as "myocarditis" or "myodegeneration" with "weakened
heart" and death as "sequelae of myocarditis". The mean age of the affected male patients reported by
Bollinger was 43 years, with a mean body weight of 71 kilograms and a mean cardiac weight of 535 grams.
This contrasts with a mean heart weight of 330-in a control group of deaths by suicide (Gocke, 1883).
Histologically, Bollinger (1886) reported broadening of myocardial fibers, enlargement of their nuclei
and an apparent fibrosis, but no fatty degeneration and no inflammatory reaction. A history of high
alcohol intake of up to 12 liters of beer daily was found in 22 of Bollinger's series of 42 patients.
Some of these patients were employed in breweries or liquor stores. Some showed other signs of chronic
alcoholism as cirrhosis of the liver, pachymenigiosis hemorrhagica, or delirium tremors.
Bollinger wrote in his textbook of pathology (1901): "Idiopathic cardiac hypertrophy usually
with dilatation is most frequently found in certain forms of chronic alcoholism (beer drinkers), whereby
plethora and toxic influences become effective as pathogenic factors. This diagnosis can only be
accepted if the usual anatomical causes for cardiac hypertrophy as valvular stenosis, arteriosclerosis,
nephritis, lung diseases etc. are absent." In this context, the term of the "Plethoric Munich Beer
Heart" was coined.
As to other possible causes for this idiopathic hypertrophy and dilatation of the heart, it has
to be mentioned that the ability to measure blood pressure by sphygmomanometer had been published 1896 by
Riva-Rocci. This occurred between Bollinger's reported series of 1886 and the publication of his
textbook in 1901. However, the reported findings of hypertrophy and dilatation of the right and the left
heart without left heart predominance is not typical of hypertensive heart disease.
Before Bollinger's reports, several observations of cardiac enlargement of unknown etiology and
pathogenesis were known. A variety of terms such as "active cardiac aneurysm", "eccentric hypertrophy"
or, more appropriately, "idiopathic, simple cardiac hypertrophy", were used by Corvisart, Bertin and
Bouillaud. Stokes (1885) described young men doing heavy labor admitted
with a "weakened heart"; most died at first admission or at re-admission. In addition to heavy labor,
physical effort in athletes, emotional stress, heavy smoking, sexual excesses and heavy drinking, often
combined with heavy eating ("bonvivants") were thought to be responsible for this heart condition. There
was a geographical gradient with only one death of myodegeneration cordis in
Berlin compared to 4.6% in Munich. The same was true for the gradient of beer consumption: 88 liters
per male per year in the entire German Empire., but 416 liters in Munich. Some brewers are reportedly
consumed 8-15 liters a day (free beer was available to workers in breweries). Additionally Bavarian beer
was stronger than in the North with 34 grams alcohol/1 liter. With increasing export of Bavarian beer to
Berlin, the number of young Berliners suffering from palpitations, dyspnea and cardiac enlargement also
Bollinger did not negate other causes for cardiac hypertrophy and dilatation, especially in older
patients. However, for younger patients the "alcoholic plethoric beer heart", for short "Munich Beer
Heart", may be a cause of death. The factors responsible for this condition apparently include not only
the intake of alcohol, but also large amounts of food or liquids. With isolated disease of the heart in
chronic alcoholism, there may be a genetic predisposition. As the typical historical background of heavy
beer drinking does not play an important role anymore, the typical "Munich Beer Heart" seems to have
vanished. Nevertheless, alcoholic myocardial damage is a disease that should not be neglected in younger
patients with heart disease in the absence of other causes. Apparently inhibition of calcium
transportation and of oxidation of fatty acids, as well as acetaldehyde breakdown products of ethanol
effect energy metabolism and contractibility of the myocardium. The histological changes consist of
nonspecific interstitial edema progressing to fibrosis. Ultrastructure shows only a suggestion of
irregularity of fibrillary structures with later deposition of lipochrome pigment in the myocardial
cells, without evidence of any further degenerative cell damage.
Finally, today as in the past, many are of the opinion that beer is an important nutrient ("liquid
bread!") and, as had been cited by a Prussian representative at the Reichstag in Berlin (January
21,1880), "Beer left undrunk is a failure to its own profession!".
Professor Bollinger's Conclusions
"About changes of a patriotic beverage: Arriving at the end of our etiological controversy, I
feel sorry to incriminate the warm supporters of a patriotic beverage. As beer in moderate consumption
possesses an unattained advantage from the hygienic standpoint as luxury and nutrition, its abuse is like
with other spirits in addition to its pernicious effects on the heart, as well as other health risks.
Extreme beer consumption in our homeland (Bavaria) also explains that hypertrophic and dilatative changes
of the heart see quite commonly, as are a great variety of other diseases. There is no doubt that these
cardiac anomalies constitute a weakening element, which drastically reduces the resistance of an
individual (especially young men)".