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 increased.

Epilogue
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)".