not pernicious anemia, and we can easily make that diagnosis by examination of the blood. The gentleman asked the question, why this case is not cured since it appears to be. Experience shows that these cases are very apt to relapse. I think Dr. Osler reports one case out of forty or fifty that has apparently been cured. Dr. Billings makes a similar report, and in these series of cases they show that many of them have periods when they are apparently well, but eventually have a relapse, and I think in this particular case under consideration we may look for the same thing, and I agree with Dr. Bell that we should keep them under observation and keep them on intermittent treatment; patients should occasionally take arsenic.

THE BOUNDARY LINE BETWEEN CHRONIC ALCOHOLISM AND ALCOHOLIC INSANITY.

ARTHUR W. DUNNING, M.D., ST. PAUL.

There is a nice distinction, and a very important one, to be drawn between the inebriate or common drunkard and the victims of various forms of true alcoholic insanity. An effort to point out and emphasize this distinction is the purpose of this paper. The general practitioner is called on not infrequently to determine whether in a given case there is an element of insanity or simply a normal wilfulness to do the wrong thing regardless of consequences. This is not always an easy matter and, unfortunately, the tendency is to overlook the early indications of mental unbalance in the sweeping classification of common drunkenness. This is unfortunate from the therapeutic standpoint, because often the time when the best results from treatment might be obtained, is allowed to slip by. Moreover the medicolegal question involved at this point is one of vast importance. Either the question of legal restraint for curative purposes, or that of the legality of business transactions and the control and saving of property, makes it necessary that the medical attendant be exceedingly careful and painstaking in his observations. How frequently we see the spectacle of a man who has borne an excellent reputation and accumulated property, gradually lose self-control through excessive drink. His property slips away through unbusiness-like deals, domestic trouble develops and his health is undermined. When called on by the probate court to examine such a man as to his sanity, great care must be exercised to avoid the error of attributing to mere drunkenness the symptoms which, if carefully studied, point with certainty to mental unbalance. Unfortunately in this state the inebriate department of our hospitals for the insane has been abolished and, as a result, the tendency is for all

alcoholic cases to be rejected by the probate court as ineligible, whereas some of them are justly cligible as cases of true insanity.

Wherein, then, lie some of the distinctive features which, if carefully looked to, will enable us to avoid falling into this error? First, a bad heritage, the well-marked neurotic family taint, the instability of organism that marks the degenerate is strong predisposing and presumptive evidence when present. It must be borne in mind also that in this type of individual mental unbalance may be caused by a surprisingly small amount of stimulation as compared with the normal individual. In like manner an injury to the head may establish a brain condition that is exceedingly intolerant to stimulation.

Then the little changes in character and disposition, the "lapses of memory and general disinterestedness in his usual affairs of life, the progressive mental weakening with consequent deterioration of the finer ethical and intellectual attainments," all go to show that dementia is beginning and that we are dealing unquestionably with an insanity. The periodic type of the "drink habit is but an epiphenomenon of a phase of periodic alienation, and should be positively designated as insanity."

Alcohol is, next to heredity, the most common single cause of insanity. To be sure, in some cases the drink habit may be, as Savage says, one of the earliest symptoms rather than the cause of the insanity. Nevertheless great care must be exercised that because of the drink habit the insanity be not overlooked. The psychoses do not arise from acute alcoholism but develop from and follow on the chronic type; the continued use of the poison for a long period of time.

The psychic disorder of alcoholism is quite characteristic. There is a weakening of the memory and the will, a perversion of the ethical sense, moral depravity, a tendency to excessive anger and periods of depression. The depression, or melancholia of the alcoholic type, is characterized by sudden and profound onset, short period of duration and complete remission.

Some years ago the writer was called on to examine in the probate court a man whose habits of intemperance were well known to both examiners and the judge. The wife of the patient had been induced to request his commitment to the state hospital because of marked changes in his disposition which caused her to fear him. This we did not realize as fully as she did, and, as his was thought to be a simple case of inebriety, he was discharged from court. Within a very few days, however, in a period of extreme mental depression, he ran a knife through his own heart. Careful inquiry of the wife and other intimates then revealed the fact that many of the little changes in character and disposition narrated above had existed for some time, and had this been apparent to us at the examination, the melancholia recognized and the patient placed under proper restraint, the tragic suicide might have been averted and possibly a cure effected.

The condition which Berkley describes as alcoholic persecutary insanity is one of the most important, because the most dangerous type we have to deal with. The onset is usually rather abrupt, and its distinguishing feature is the wide range of illusions and hallucinations, innumerable and changeable, coupled with suspicions of persecution. It is strikingly like paranoia, but is less definitely limited to the single idea. It is sometimes called "pseudo paranoia." Another phase of the mental disorder of the alcoholic is a peculiar loss of the sense of time and place. This, it seems to the writer, is most apt to occur in the class of cases which are associated with multiple neuritis. In a case recently under observation this feature was so marked that it was impossible to impress on the man's mind the day of the week or month, or the hour of the day to a degree that he would retain it for more than a very few minutes, although he was so bright otherwise that a stranger might converse with him for some time without discovering anything abnormal. He showed other traits at times, however, which rendered the diagnosis of alcoholic insanity absolute. These were inordinate anger and jealousy, coupled with illusions and hallucinations. There were some physical signs also which made the case

appear strikingly like general paresis, but here, again, the history alone marked the difference; the chronic alcoholism was followed by multiple neuritis; the latter accounts for the loss of the deep reflexes, the amnesia and the illusions, which are so suggestive of the graver disorder, general paresis. This case affords, it seems to me, a very excellent example of what Berkley describes as "pseudo paresis," the chief characteristic of which is that it develops from chronic alcoholism, and is, in a measure, at least, and under proper conditions, curable.

In the type of dipsomania or periodic drinking, when mental decay is just beginning to be noticeable, I have noted one feature which seems to me to be worthy of mention, that is that when under absolute control and with the entire withdrawal of all alcoholic stimulants there will yet appear periodically a condition so closely resembling alcoholic intoxication as to cause one almost to doubt both his patient and nurse when they stoutly affirm that he has had no alcoholic drink. The face becomes flushed, the eyes suffused, the lips and tongue parched, and the mental state chaotic, while the individual disposition as to temper, jealousy, etc., are markedly altered. The condition is so marked withal and is, in itself, so significant that surely there can be no doubt when it occurs that that man requires complete restraint and control for a prolonged period, nor should there be any difficulty in procuring over him legal restraint on the ground of insanity.

In the foregoing, then, I have suggested some of the indications of insanity developing from chronic alcoholism.

On the other hand the simple chronic alcoholic exhibits no marked change in disposition, is not absentminded in the same degree, and he knows very well the results of alcoholic debauch. The law justly holds him responsible for his acts when intoxicated, and he must bear the consequences of bad business deals made while in that condition.

The points, then, which I wish to emphasize are:

1. The early recognition of insanity of this type is very important, but often exceedingly difficult.