ALCOHOLIC PSYCHOSES: CLINICAL ASPECTS

AND DIFFERENTIAL DIAGNOSES.

CHARLES E. STANLEY, M.D.,

MIDDLETOWN.

Of the 996 cases of insanity (523 males, 471 females) admitted to the Connecticut Hospital for Insane for the years 1899 and 1900, ninety-five were of alcoholic origin. Eighty, or sixteen per cent. of the male admissions, were due directly to alcohol. From this statement it would appear that alcohol exerts a most deleterious effect on the mind, producing psychic debasement.

In seeking the truth regarding the evil effects (immediate and remote) of alcohol, the tendency to-day, I believe, is to underrate its poisonous and deteriorating influence on the race. In the last fifty or seventy-five years temperance reformers and others have unintentionally greatly exaggerated the evils arising from its abuse, and prohibitory laws, based on these mistaken ideas, have proved too abrupt and radical, and have consequently been ineffectual and productive of little real benefit.

There is no nation, and hardly a tribe of the human race, which has not succeeded in inventing some method of producing intoxication, and, of all intoxicants which are, or have been in use by mankind, alcohol easily takes the lead. Civilization has greatly multiplied the number and uses of stimulants, and commerce has made the product of each clime the property of all. Our remote ancestors indulged only in home-made varieties, but we moderns are content with only all of the best the world produces. The vine is supposed to have had its origin in India. The Romans introduced it into England. It was not, however, until about the sixteenth century that wine

bibbling in Great Britain became the common practice of all possessing sufficient means to indulge the habit. In speaking of the prevalence of the drink habit in our time, Doctor Kerr (alienist and author of a work on inebriety) states that there is scarcely a family in the United States or Great Britain which has not at least one relative who has been the subject of inebriety.

The symptoms of alcoholic intoxication described by medical men of olden times, differ materially from those ascribed to the alcoholism of to-day. This is accounted for, in part, at least, by the kind, quantity and particularly by the adulteration of the liquors imbibed. Physicians of to-day not only have to note the poisonous effect of the narcotic on the individual, but must also study the individual himself. In other words, individual inheritance plays a prominent role in the alcoholism of the present day. Unfortunately, the greatest predisposing factor to the disease to-day lies in the individual himself. Until comparatively recently the writings of medical men contain no mention of the narcotic or neurotic diathesis of which we hear so much at present, and which undoubtedly is the underlying cause of many nervous and mental diseases. Evidences of degeneration, of alcoholic origin, in individuals and families are only too apparent. Anstie puts it very forcibly thus: "Nervous enfeeblement produced in an ancestor by great excesses in drink is reproduced in his various descendants with the effect of producing in one insanity, in a second, epilepsy, in a third, alcoholic excesses, neuralgia, hysteria, and the whole train of nervous disorders. Idiocy, imbecility and criminality might also be added to the list.

All unbiased thinkers admit the value of alcohol in certain diseased conditions of the body, when judiciously employed by the physician. In moderate amounts it increases the flow of ideas, renders the senses more acute, speech more fluent, and movements more active. The physiological action, however, may be quickly trans

cended and the toxic influence obtained, by the frequent ingestion of the drug, even in moderate amounts, and despite its rapid elimination. The difference between its physiological and toxic effect is merely one of degree and varies with the individual affected.

Nearly, if not all the symptoms of the different forms of insanity, are obtained in one or other of the phases of acute alcoholic intoxication. In the rapid release of ideas and motor impulses generally, the excitement, restlessness, talkativeness and distractibility of the beginning stage of exhilaration, is noted a marked resemblance to periodical insanity. manical form; on the other hand, the symptoms of depression with slowness of speech and retardation of thought and movement, of a later stage, are characteristic of depressive mania; and, lastly, the expansiveness, extravagant speech, rapidly changing emotional states, unequally dilated pupils, ataxie gait, sluggishness, stupor and paralysis of the last stage of alcoholic intoxication, furnish a picture of general paralysis.

By repeated poisonings of the system with alcohol, chronic alcoholism results, with the effect that the moral sense is perverted and enfeebled; the will is weakened and becomes uncertain and vacillating; and, at last, the intellect is progressively invaded until psychic debasement is complete. The process of deterioration. so gradual as to be barely detected at first, finally becomes general, ending in moral and mental ruin.

In chronic alcoholism there may develop a condition resembling general paralysis of the insane which has been denominated alcoholic pseudo-paresis. It is often difficult to differentiate the two diseases. In both there is gradual and progressive impairment of memory and judgment with stupidity, hallucinations, weak expansiveness, a sense of well-being, and delusions of persecution and infidelity. Physically, each is accompanied by muscular tremor, absent or exaggerated tendon reflexes,

ataxia, disturbance of speech, and not rarely by epileptiform attacks. In alcoholic paresis, while the course may be protracted, yet in time the more marked symptoms disappear or remain stationary; in general paresis, the course progresses to a fatal termination. The paretic is more indifferent and less logical than the alcoholic, reacts less to hallucinations, delusions, or emotions of fear, etc. In both diseases, the pathological changes in the brain are similar. The granulations in the ventricles of the paretic are absent in the alcoholic according to Krafft-Ebing.

In a small group of cases of chronic alcoholism, with no clouding of consciousness, persistent but feebly systematized delusions of jealousy gradually develop. Although scarcely worthy of being designated a psychosis, it is known as alcoholic paranoia. The most marked and diagnostic symptom of the disease is a delusion of infidelity entertained by wife for husband or husband for wife, growing out of the estrangement which naturally arises from excessive indulgence in alcoholics. Failing sexual powers, due to alcoholism, may also be a factor. The patient's jealousy is aroused by the most trivial circumstances, such as a word or glance. Neighbors, callers, and others are often drawn into the family strife. Delusions of poisoning also are sometimes associated with delusions of infidelity. Frequently the patients react emotionally to their delusions, concerning which their reasoning is weak and absurd, and with which their actions are often strangely at variance. The disease is differentiated from true paranoia by the lack of system in the delusions, and by the symptoms of chronic alcoholism. Prognosis is poor in these cases. They may be made comfortable by the change of environment and abstinence from alcoholics, but a return to their homes and alcohol soon relights the same train of symptoms.

Finally, upon a basis of chronic alcoholism, two very

important psychoses may arise, viz.: alcoholic delirium and alcoholic delusional insanity.

Alcoholic delirium is sudden in its onset and attended by more or less clouding of consciousness. Its peculiar symptoms are due to nutritional changes in the cell elements of the gray matter of the brain, and may occur either after excessive indulgence in alcoholics or after their sudden withdrawal. One of the most striking peculiarities of the delirium relates to the hallucinations, which accompany it. These are, almost without exception, visual in character, although illusions or hallucinations of any or all of the other senses may also be pres ent. The erroneous perceptions are numerous, embrace all manner of living, creeping things, often grotesque in form and terrifying in character, and which are always in constant motion. In contradistinction to the above, in ordinary delirium (of pneumonia, typhoid fever, etc.), the hallucinations are single and fixed. A second peculiarity is noticed in the restlessness of the delirium. The patient is uneasy and always on the alert, and finds rest nowhere. Emotionally, he is apprehensive, fearful that some calamity threatens or that some evil is about to befall him. Reacting to hallucinations he peers beneath the bed, and into corners and closets in search of some realizations of the fears that torment him. His fear is increased to terror by the ever-varying but constant hallucinations, and in his endeavors to escape, he may do bodily injury to himself or others. Physically, the chief diagnostic symptom is tremor; gastritis may also be present. With supportive measures generally, the main indication in treatment is to promote sleep; with this accomplished, the delirium subsides in from three to twelve days. Recovery is the rule; death occasionally results from exhaustion or complications, and chronic insanity claims now and then a case.

Finally, one of the most interesting of the alcoholic psychoses, is that described and denominated by Prof.