THE ALCOHOLIC PSYCHOSES
According to Tuke,[213] one of the oldest of the Egyptian papyri in the
British Museum (Papyrus Sallier I) makes the following very interesting
reference to alcoholism:— "Whereas it has been told me that thou hast
forsaken books, and devoted thyself to pleasure; that thou goest from
tavern to tavern, smelling of beer, at the time of evening. If beer
gets into a man it overcomes his mind.... Thou knowest that wine is an
abomination, that thou hast taken an oath that thou wouldst not put
liquor into thee. Hast thou forgotten thy resolution?" It is difficult
to realize that this refers to one of the earliest periods of recorded
history. Hebrew, Greek and Roman literature are prolific in equally
significant testimonials to the antiquity of alcohol as an intoxicant.
It was referred to at considerable length by Aristotle, Plutarch and
Hippocrates. That Haslam appreciated the important relation existing
between alcoholism and mental disorders is shown by the following
comment on this subject written in 1808:—"Thus a man is permitted
slowly to poison and destroy himself; to produce a state of irritation,
which disqualifies him from any of the useful purposes of life; to
squander his property among the most worthless and abandoned; to
communicate a loathsome and disgraceful disease to a virtuous wife; to
leave an innocent and helpless family to the meagre protection of the
parish. If it be possible the law ought to define the circumstances
under which it becomes justifiable to restrain a human being from
effecting his own destruction, and involving his family in misery and
ruin. When a man suddenly bursts through the barriers of established
opinion; if he attempts to strangle himself with a cord, to divide his
large blood vessels with a knife, or swallow a vial full of laudanum,
no one entertains any doubt about his being a proper subject for the
superintendence of keepers; but he is allowed, without control, by a
gradual process, to undermine the fabric of his health and destroy the
property of his family."
Curiously enough the word alcohol is of Arabic origin and was employed
originally to describe a powder used in applications to the eyebrows
for cosmetic purposes. It was subsequently used for centuries as
referring to a fine powder of any kind, as is shown by the writings
of Paracelsus and others. The chemical composition of alcohol was not
known until 1808, when it was described by Lavoisier. On the other
hand, Salvatori in 1817 and Hufeland in 1818 referred to dipsomania
as a disorder due to alcoholism. Esquirol, Trélat and other early
writers included it in the "partial" insanities. Morel described it
as an impulsive form of "délire émotif" and looked upon it as an
hereditary condition. It has been classified with the periodical
insanities and even as a form of melancholia. Magnan saw in it an
episode of the insanity of degeneracy. Magnus Huss was responsible for
the introduction of the term "chronic alcoholism" as descriptive of a
pathological condition in 1852.
It is said that Caelius Aurelianus protested against the use of
intoxicants in the treatment of the insane. Notwithstanding this early
reference to a question of such importance, and the inauguration of
the great temperance crusade which began in 1808, it has been shown
by Tuke[214] that alcoholic beverages were issued in a routine way to
patients and employees of the British asylums for the insane less than
forty years ago. "Thirty superintendents hold that they have observed
very beneficial results from the course pursued. The improvement
usually refers not only to the patients, but to the discipline of the
asylum." The cost of beer supplied to the inmates at the Glamorgan
Asylum at one time was reported to be as high as two hundred and sixty
pounds per year (Tuke). Beer was not discontinued as a regular article
of diet for patients at the Derby Asylum until 1884.
In 1844 Flemming[215] in his classification of psychoses mentioned
the following forms of alcoholic insanity:— Ferocitas et morositas
ebriosorum, anoësia e potu, anoësia semisomnis, delirium tremens, and
mania à potu. Clouston[216] described acute and chronic forms—mania à
potu, dipsomania, alcoholic dementia and degeneration. Krafft-Ebing[217]
speaks of hallucinations of the inebriate, delirium tremens, alcoholic
melancholia, mania gravis potatorum, hallucinatory insanity, alcoholic
paranoia, alcoholic paralysis and epilepsy. Delirium tremens he
ascribes either to repeated excesses (à potu nimio), abstinence (à potu
intermisso), insufficient nourishment, violent emotions, pneumonia and
other acute diseases, loss of sleep, injuries such as fractures, etc.
By hallucination of the inebriate (sensuum fallacia ebriosa) he refers
to the transitory hallucinations of the constant drinker. Meyer[218]
has described an alcoholic constitution "as shown by the lachrymose,
prevaricating, jealous deterioration of the drinker."
Stöcker,[219] after an extended study of a considerable number of
cases, came to the conclusion that alcoholism is the result of a
constitutional condition but not the cause of characteristic psychoses.
Often, as was also shown by Bonhöffer, it is to be attributed to
a psychopathic personality either acquired or congenital. The
psychoses represented by the group of patients he examined included
manic-depressive insanity, dementia praecox, hysteria, epilepsy and
other miscellaneous conditions. He refers to dipsomania as an epileptic
equivalent. His conclusions in brief were as follows:—"Chronic
alcoholism in the first place is a symptom of a mental disease. It may,
however, so exaggerate stationary epilepsy, chronic mania, dementia
praecox, etc., which hitherto were latent, and perhaps would remain
still latent without alcoholic abuses, that it may lead to a sudden
outbreak of a turbulent disease manifestation. It may also give these
diseases peculiar traits or a peculiar coloring for some time, which
above all, may appear as the most striking phenomena, and thus cover up
the symptoms of the fundamental disorder. Furthermore, it may, also,
on the basis of this constitutional disease give rise to independent
clinical pictures." Karpas[220] in commenting on this says: "One must
remember that cravings play important rôles in our mental life. Some
of our cravings are gratified; others find realization in our dreams;
still others are repressed and compensated. In fact, our mental
life is nothing but a readjustment, of complex reactions. The poet
finds recourse in his phantasies; the philosopher gives vent to his
theoretical speculations; the scientist resorts to his inventions and
hypothetical theories; the well balanced, normal individual seeks
readjustment in healthy activities,—art, literature, science,
occupations, sport, etc., etc. But the individual with a poorly endowed
constitution finds refuge in neurosis, psychosis, alcoholism, drugs,
and other vicious habits. We must recognize that alcoholism is nothing
but a compensation for a complex, the fulfillment of which was denied
by reality."
Kraepelin[221] described acute and chronic alcoholism, pathological
intoxication, alcoholic jealousy, delirium tremens, Korsakow's
psychosis, alcoholic hallucinoses, paralysis and pseudo-paresis. In
acute intoxication Kraepelin finds an inhibition of apprehension,
mental grasp and the elaboration of outer impressions with a
stimulation of the release of volitional impulses. A clouding of
consciousness develops, associated with emotional excitement and a
weakness of will power. Perception and mental reactions are delayed
and their accuracy decreased on mental tests. The discrimination
between louder sounds is uncertain, although the sensitiveness to
lighter sound impressions is increased as in the ether narcosis.
Busch found a limitation of the field of vision. The preservation of
memory impressions is imperfect. A solution of mathematical problems
shows a lowered mental capacity for work. The association of ideas
and composition of sentences is delayed. There is a tendency to
new word formation, phrasing and rhyming, with a certain amount of
distractibility. Goal ideas are often missed, and consistent, orderly
thought is not possible. Expression is rapid and impulsive, and is
often characterized by a loud tone of voice.
After larger amounts of alcohol psychomotor activities are interfered
with as shown by the writing, and ataxia appears. The reflexes show an
increased muscular tension. Physical strength is markedly lowered,
although it may be increased for a very short time. Alcohol even in
small amounts interferes with productive mental processes. Ideas lose
in clearness and sharpness, fatigue occurs earlier and efficiency and
judgment are impaired. Still larger amounts retard apprehension and
comprehension and the intoxicated person no longer knows what is said
to him. All ability to control his conduct is lost. There is a tendency
to repetition in speech, rhyming and jargon. Capacity for mental work
is finally entirely gone and memory becomes confused. Psychomotor
stimulation and excitement appear early, terminating finally in
weakness. Emotional trends, at first happy and cheerful, are usually
irritable, later with outbursts of anger. Sexual excitement often
appears. Various physical disturbances have been described.
In the pathological or complicated intoxications as described
by Kraepelin, unusual emotional disturbances such as violent
excitements occur. Anger or anxiety may develop with a clouding of
the consciousness, and lead to uncontrollable rages with impulses to
assault and kill. The most marked excitements occur in epileptics.
The outburst is usually sudden in these cases and is followed by the
most senseless and unjustifiable acts. Occasionally suicide is the
result. In hysterical and psychopathic individuals alcohol may cause
serious emotional disturbances, with clouding of consciousness or even
delusion formation. Chronic drinkers are very likely to have abnormal
symptoms at times. They often show a marked irritability followed
by a pathetic and tearful mood. Abusive treatment of members of the
family, jealousy, threats and violence are not uncommon. Delirious or
anxious states with persecutory ideas and hallucinations are sometimes
observed. These may exist only during intoxication. Alcohol often
produces extreme excitements in cases of manic-depressive insanity,
general paresis and dementia praecox. Pathological changes of various
kinds have been reported. In acute alcoholism Nissl found a destruction
of cortical cells in some cases and a disappearance of the stainable
lumps in others. The nuclei of the neurones were shrunken and sometimes
displaced.
Various tests have demonstrated the limited mental capacity of the
chronic alcoholic. Will power is greatly reduced and fatigability
increased. Memory and attention are affected and falsification of
the past may occur. The patient learns nothing new and forgets the
important things. All productive efficiency is gone and interest is
lost. Weakness of judgment and loss of memory capacity lead to delusion
formation. These often take the form of ideas of jealousy. Delusions
of persecution, poisoning or grandeur may appear from time to time.
Frequently there are genuine hallucinations. Some cases terminate
finally in mental enfeeblement. Emotional changes are common in the
chronic drinkers. The alcoholic humor is characteristic. The capacity
for taking things seriously has been lost and there is a tendency to
undue levity, often with a marked feeling of self-satisfaction. Some
individuals, however, become moody, irritable or dull. Occasionally
anxious states appear, frequently with suicidal attempts. One of the
common symptoms of this condition is an extraordinary irritability
after drinking. This leads to quarrels, assaults and violence.
Consideration for others is completely lost. These attacks are often
followed by remorse. A prominent and significant feature of the
disease is the marked moral deterioration. All affection for family
and children may be lost. Selfishness is pronounced and the patient
spends all of his money for drink. Sexual excitement is sometimes
an important symptom. With all of this there is a constant craving
for alcohol. The patients have no insight into their condition and
attribute their headache and tremors to overexertion, etc. They always
deny using much alcohol and are absolutely untruthful on this subject.
Overwork necessitates drinking, or it only happens after a death in the
family, etc. Will power deteriorates rapidly. These individuals often
commit crimes and come into conflict with the law. Gastritis, cirrhosis
of the liver and numerous other diseases complicate the situation.
Dizzy spells and headaches are common, as well as tremors of the
tongue and fingers. Neurotic involvements are noted, with anesthesias,
hyperesthesias, paresthesias, and muscular atrophies as well as speech
defects. Epileptiform attacks are not infrequent in chronic alcoholism,
and were found in ten per cent of Kraepelin's cases. His investigations
showed that eleven per cent of the beer drinkers in Munich had
convulsions. Combinations of epilepsy and hysterical manifestations
with chronic alcoholism are not at all unusual. Rybakoff found a
hereditary taint in 66.6 per cent of his cases while Moli reported only
forty-seven per cent. Heredity was found to be a factor in thirty-seven
per cent of Kraepelin's Heidelberg cases and in seventeen per cent
of those at Munich. He describes various pathological findings in
chronic alcoholism. Meningitis with hemorrhagic membranes is common.
The convolutions are atrophied and the ependyma of the ventricles
thickened. Pigmentary deposits similar to those of senility are found
in the cells and vessel walls. There is an increase of both neuroglia
cells and fibres. Hemorrhages are occasionally found in the central
gray matter.
When the suspicions of the chronic alcoholic lead to well defined
delusions Kraepelin speaks of "alcoholic jealousy" as constituting a
distinct psychosis. The patient sees in almost everything evidences of
infidelity on the part of his wife and is often inclined to question
the legitimacy of his own children. Assaults and violence are frequent
occurrences. Occasionally genuine hallucinations accompany this
condition. Suicidal and homicidal attempts are not uncommon.
The onset of delirium tremens, first described by Thomas Sutton in
1813, is characterized by states of anxiety, fear, insomnia with
disturbing dreams, sensory excitement, hyperesthesias, flashes
of light, etc. The development usually is sudden, with a loss of
attention, disturbance of apprehension, restlessness, distractibility,
numerous hallucinations of the different senses, illusions, clouded
states with disorientation, tremors and ataxia. Touch, pain and
temperature sensations, according to Kraepelin, are undisturbed.
The field of vision is sometimes narrowed. Recognition of colors is
uncertain. There is a marked disturbance of the equilibrium, suggesting
some lesion either of the eye muscles or of the labyrinth. A decided
lengthening of the reaction time in associations has been shown by
various observers. Sensory hallucinations are common. The ability
to read correctly is entirely lost and what is read is meaningless.
A paraphasic form of reading has been described by Bonhöffer. The
attention cannot be held for any length of time. A dreamy clouded state
is characteristic. Disorientation is usually complete in the severe
cases. The hallucinations and illusions are very marked and sometimes
even suggest moving pictures to the patient. Hallucinations of vision
are more common than those of hearing. Peculiar skin sensations such as
feelings of electricity are spoken of. Hallucinations may be induced
by pressure on the eyeball and sometimes by suggestion. There is
occasionally a confusional form of speech suggesting dementia praecox,
with a tendency to coin new words and employ entirely meaningless
terms. Although consciousness is not always entirely clouded, events
transpire as in a dream, always confused by innumerable hallucinations.
An occupation delirium is common, the patient imagining himself busy
at his customary work. Delusional ideas regarding everything in his
surroundings are frequent. Ideas of grandeur sometimes occur. Never,
according to Bonhöffer, is there a complete disorientation as far as
personality is concerned. The patient always knows who and what he is.
Complete mental confusion is not the rule. Distractibility is usually
very well developed. Bonhöffer found an inability to supply omitted
words and syllables from well known phrases and memory for test words
and numbers was impaired. Articles read are repeated with many changes
and omissions. Memory for remote events is usually well preserved.
Sometimes there is a falsification of the past. The mood is anxious,
fearful, seldom irritable, at times actually humorous. Cheerfulness and
fear of death occasionally alternate.
The course of the disease is characterized by great restlessness often
with a tendency to talkativeness. There is, however, no flight of ideas
or rhyming. Delusions of persecution occur in some cases. Anesthesias,
hyperesthesias, paresthesias, hypalgesias and sensitiveness of nerves
and muscles are noted. Romberg's sign is present in some instances.
Speech is often ataxic and paraphasic, and in advanced eases entirely
meaningless. Tremors of the tongue and fingers are very characteristic.
Writing is very much affected as a result. Epileptiform convulsions
sometimes occur. Rarely focal symptoms, facial paralysis and hemiplegia
appear for a short time. Reflexes are increased and ankle clonus
occasionally appears. Defective papillary reaction and unequal pupils
may be found, with diplopia and muscular weakness. Sleep is seriously
interfered with. Bodily weight is reduced and blood pressure lowered.
The temperature is usually elevated and the pulse accelerated. Albumen
and sometimes sugar is present in the urine. The delirium often stops
as suddenly as it begins, terminating in sleep, the patient being
clear when he wakes. The memory of events is not well retained on
recovery. The delirium may, however, become chronic and last for
months. Some cases terminate in a hallucinatory feeblemindedness.
This is likely to occur in psychopathic individuals. Hallucinations
of hearing are more common in such conditions. People read their
thoughts and influence their minds. They are subjected to hypnotism
and electricity. The delusional ideas may be of a sexual nature or
grandiose in character. The mood may be anxious or irritable. Suicidal
tendencies sometimes appear. Later a humorous trend is often noted.
Tremors and other neurological symptoms sometimes occur. Bonhöffer
found at autopsy a considerable fibre loss in the central convolutions,
the cerebellum and the column of Goll. In the large pyramidal and
motor cells of the anterior central convolution the processes were
deeply stained. Some nuclear changes were noted and occasional cells
destroyed. Nissl described a granular degeneration of the neurones
with a prominence of the "unstainable" substance, together with a
swelling and crumbling of the cell bodies. Alzheimer often found free
nuclei near the apical processes. In the glia cells and vessel walls
granular detritus was observed. Acute and chronic cell alterations
are more common in old alcoholics. Pachymeningitis hemorrhagica is
sometimes found. Kraepelin considers it very doubtful whether wine or
beer drinking ever causes delirium tremens, whisky and gin being the
etiological factors as a general rule.
Korsakow's psychosis was first described in 1887. This is characterized
by a loss of memory, and falsification, with a marked tendency
to disorientation, and is often due to chronic alcoholism. It is
practically always accompanied by polyneuritic symptoms. According
to Bonhöffer, it usually follows delirium tremens. This occurred in
one-fourth of Kraepelin's cases. Occasionally it begins suddenly, but
as a rule gradually, during the course of a chronic alcoholism. The
patients frequently complain of dizziness, headaches and fainting
spells. In the foreground of this affection is the impairment of
memory. This is one of the characteristic features. The events of a
few hours ago are completely forgotten. Disorientation appears next.
This affects time more than anything else. The power of apprehension
or perception is very markedly impaired (one-sixth of the normal in
Kraepelin's cases) and the reaction time is greatly increased. He
also found memory reduced to one-third or one-fourth of the normal on
actual tests (repetition of words and syllables). Falsification of past
events is also demonstrable. This often leads to elaborate delusion
formations. The mood is usually anxious at first, later indifferent,
dull, suspicious, irritable, in some eases cheerful and even humorous.
The methods of life are completely changed. The patients neglect
themselves, lie in bed, etc. The physical signs are those of neuritis.
Muscular pains in the limbs appear, with evidences of loss of power.
Paraplegias and weakness of the grip are found. Romberg's sign is
frequently present. Anesthesias, hyperesthesias or paresthesias are
noted. The reflexes are usually decreased, rarely increased. Ataxia and
other difficulties of gait are common. The pulse is usually slower as a
result of involvement of the vagus. Speech difficulty, writing defects,
facial paralyses, weakness of the eye muscles, with inequality and
inactivity of the pupils, are to be expected. There are usually tremors
of the fingers. Epileptiform convulsions are not infrequent. Aphasia,
agraphia, apraxia, monoplegia, hemiplegic, etc., are observed in many
cases. Physical disturbances of various kinds due to chronic alcoholism
are also present.
At autopsy acute and grave alterations are found in the cells of the
second and third layers of the cortex. A granular degeneration (Körnig
Zellerkrankung) of the cells is also referred to by Nissl. There is
some fibre loss in the central convolutions and the internal capsule,
as well as in the columns of Goll. Hemorrhages and thromboses are to
be found. Alzheimer found encephalitic foci with proliferation of the
cells of the vessel walls sending out fibroblasts in the neighborhood,
and a destruction of the nerve fibres. These foci are found in the
central gray matter of the third ventricle, roof of the aqueduct,
etc. There is a formation of new vessels and an outwandering of cells
often accompanied by numerous hemorrhages into the gray matter around
the aqueduct of Sylvius. Wernieke has described this process as an
"acute hemorrhagic polioencephalitis superior" and finds it very
commonly associated with Korsakow's psychosis. It occurs, however, in
other chronic alcoholic conditions. The peripheral nerves also show a
polyneuritis. Bonhöffer found Korsakow's psychosis in three per cent
of his delirious cases. Thirty-three per cent of Kraepelin's cases
were women and only 24.5 per cent were under forty years of age.
Chotzen found Korsakow's psychosis in three per cent of his male and in
twenty-one per cent of his female alcoholics.
The acute alcoholic hallucinoses as described by Kraepelin are
characterized by well defined delusions of persecution and above all by
hallucinations of hearing, with a clear sensorium. In eighty per cent
of the cases the symptoms appear suddenly. Sometimes there is first an
abortive delirious attack. Usually a multiplicity of hallucinations of
hearing develop early. The patient hears threats and abusive language,
always directed against himself. Visual hallucinations also occur,
particularly at night. The other sensory fields are often involved.
At the same time well marked delusions manifest themselves. These
suggest every possible variety of persecution. Ideas of grandeur
are sometimes observed. All of these symptoms are worse at night
as a rule. Consciousness is usually fairly clear, and there is no
disorientation. There is often a mixture of anxiety and humor. Some
cases, however, are irritable and suspicious. Occasionally suicidal
tendencies appear. Conduct is usually not greatly disturbed and the
patient continues with his regular occupation. There is considerable
insomnia and a tendency to run around a great deal and act foolishly
at times. Physically, evidences of chronic alcoholism are always to be
found. The customary duration of these acute conditions is from three
to eight weeks, although they sometimes last for months. In a quarter
of Kraepelin's cases the termination was in deterioration. There is a
strong tendency to recurrence. The unrecovered cases are suspicious,
surly, quarrelsome and have hallucinations of hearing. This condition
may last for years. There are always occasional persecutory ideas.
One-fifth of Kraepelin's cases became chronic. Bonhöffer described a
paranoid type of long duration. The hallucinoses appear usually earlier
in life than Korsakow's psychosis but later than delirium tremens. In
Kraepelin's experience delirium tremens is three times as common as are
hallucinoses. He looks upon these two conditions, however, as different
clinical manifestations of "one and the same" disease process.
Alcoholic paralysis, so called, is a mixture of chronic alcoholic
symptoms with those of general paresis. There is a mental deterioration
with ideas of grandeur, emotional dulness, hallucinations, delusions
of jealousy, speech defect, tremors and polyneuritis. Epileptiform
attacks are frequent. Most of these forms according to Kraepelin
belong to Korsakow's psychosis or polioencephalitis hemorrhagica
superior. Alcoholic conditions may also be complicated by syphilis or
arteriosclerosis.
Since the alcoholic psychoses have been generally recognized as
such, there has been comparatively little difference of opinion as to
their differentiation. The classification of the American Psychiatric
Association is as follows:—
"The diagnosis of alcoholic psychosis should be restricted to those
mental disorders arising, with few exceptions, in connection with
_chronic_ drinking and presenting fairly well defined symptom-pictures.
One must guard against making the alcoholic group too inclusive.
Overindulgence in alcohol is often found to be merely a symptom
of another psychosis, or at any rate may be incidental to another
psychosis, such as general paralysis, manic-depressive insanity,
dementia praecox, epilepsy, etc. The cases to be regarded as alcoholic
psychoses which do not result from chronic drinking are the episodic
attacks in some psychopathic personalities, the dipsomanias (the true
periodic drinkers) and pathological intoxication, any of which may
develop as the result of a single imbibition or a relatively short
spree.
"The following alcoholic reactions usually present symptoms distinctive
enough to allow of clinical differentiation:
"(a) Pathological intoxication: An unusual or abnormal immediate
reaction to taking a large or small amount of alcohol. Essentially an
acute mental disturbance of short duration characterized usually by
an excitement or furor with confusion and hallucinations, followed by
amnesia.
"(b) Delirium tremens: An hallucinatory delirium with marked general
tremor and toxic symptoms.
"(c) Korsakow's psychosis: This occurs with or without polyneuritis.
The delirious type is not readily differentiated in the early stages
from severe delirium tremens but is more protracted. The non-delirious
type presents a characteristic retention defect with disorientation,
fabrication, suggestibility and tendency to misidentify persons.
Hallucinations are frequent after the acute phase.
"(d) Acute hallucinosis: This is chiefly an auditory hallucinosis of
rapid development with clearness of the sensorium, marked fears, and a
more or less systematized persecutory trend.
"(e) Chronic hallucinosis: This is an infrequent type which may be
regarded as the persistence of the symptoms of the acute hallucinosis
without change in the character of the symptoms except perhaps
a gradual lessening of the emotional reaction accompanying the
hallucinations.
"(f) Acute paranoid type: Suspicions, misinterpretations, and
persecutory ideas, often a jealous trend, hallucinations usually
subordinate; clearing up on withdrawal of alcohol.
"(g) Chronic paranoid type: Persistence of symptoms of the acute
paranoid type with fixed delusions of persecution or jealousy usually
not influenced by withdrawal of alcohol; difficult to differentiate
from non-alcoholic paranoid states or dementia praecox.
"(h) Alcoholic deterioration: A slowly developing ethical, volitional
and emotional change in the habitual drinker; apparently relatively few
cases are committed, as the mental symptoms are not usually looked upon
as sufficient to justify the diagnosis of a definite psychosis. The
chief symptoms are ill humor and irascibility or a jovial, careless,
flippant, facetious mood; abusiveness to family, unreliability and
tendency to prevarication; in some cases definite suspicions and
jealousy; there is a general lessening of efficiency and capacity
for physical and mental work; memory not seriously impaired. To be
excluded are residual defects due to Korsakow's psychosis, or mental
deterioration due to arteriosclerosis or to traumatic lesions.
"(i) Other types, acute or chronic (to be specified)."
Shadwell[222] states that in twenty-six Italian asylums 18.6 per cent
of their cases were directly or indirectly the result of alcoholism.
Twenty-one and one-tenth per cent of the males and 4.37 per cent of
the females admitted to the institutions of Switzerland from 1901 to
1904 were alcoholics. Twenty-one and thirty-seven hundredths per cent
of the admissions to the hospitals in Denmark between 1899 and 1903
were suffering from alcoholic psychoses. He gives the admission rate
in Austria as fourteen per cent and in France, 12.5 per cent. Clouston
some years ago estimated the admission rate in Great Britain and
Ireland to be about twenty per cent.
Pollock[223] has made a most interesting study of 1,739 cases of
alcoholic psychoses, the total number admitted to the New York state
hospitals between October 1, 1909, and September 30, 1912. Seventy-six
and five-tenths per cent of these were men, and 23.5 per cent, women.
The different conditions represented were as follows: Pathological
intoxication, .7 per cent; alcoholic deterioration, 7.7 per cent;
delirium tremens, 4.7 per cent; Korsakow's psychosis, 18.8 per cent;
acute hallucinosis, 36.7 per cent; chronic hallucinosis, 2.2 per cent;
paranoid states, 13.7 per cent; and all other forms, 15.5 per cent.
Among the males, acute hallucinosis predominated, while Korsakow's
psychosis constituted the largest percentage in the female patients.
Of the ascertained cases, .4 per cent showed a defective make-up, 10.3
per cent were inferior and 89.3 per cent were reported as normal. In
seventy-four per cent of the cases there was no history of insane
heredity. The father of the patient was insane in 3.7 per cent of the
series and the mother in four per cent; 25.8 per cent in all had a
history of insane heredity. Thirty and five-tenths per cent of the
male and thirty-seven per cent of the female patients had alcoholic
fathers and three per cent of the men and 8.8 per cent of the women
had alcoholic mothers. Pollock found the percentage of intemperate
fathers twice as high in the alcoholic psychoses as in the patients
suffering from other conditions. In 94.1 per cent of the cases there
was no family history of nervous diseases. Eighty-one and one-tenth per
cent of the men and 93.4 per cent of the women came from cities. Of the
male patients 26.8 per cent were unskilled laborers; 16.1 per cent of
the women were seamstresses, and 11.7 per cent, the wives of laborers.
The alcoholic cases constituted fifteen per cent of the male, five per
cent of the female, and ten per cent of the total first rate admissions
during the three years in question. The rate of alcoholic psychoses was
over twice in as great in the foreign born population as in the native.
Three thousand four hundred and sixty-two cases diagnosed as alcoholic
psychoses were admitted to the New York state hospitals during a
period of eight years (1912 to 1919 inclusive). Of these, pathological
intoxication constituted 2.91 per cent, delirium tremens, 5.97 per
cent, Korsakow's psychosis, 20.94 per cent, acute hallucinosis, 37.31
per cent, chronic hallucinosis, 3.66 per cent, acute paranoid states,
5.01 per cent, chronic paranoid states, 3.78 per cent, and alcoholic
deterioration, 8.34 per cent. The remainder represented miscellaneous
types variously described. These figures, of course, relate largely
to a time when there were no restrictions on the sale of alcoholic
beverages. During 1918 and 1919 the admission rate for alcoholic
psychoses in New York was only 4.58 per cent. In Massachusetts in 1919
it was 7.47 per cent, and in twenty-one other hospitals in various
states it was 5.04 per cent. A study of 34,935 first admissions to
forty-eight hospitals in sixteen different states during 1917, 1918 and
1919 showed the alcoholic psychoses to represent 5.07 per cent of the
total number. With the advent of prohibition the alcoholic psychoses
as far as this country is concerned have become a matter of little more
than historical interest. The admission rate in the New York state
hospitals for 1920 was only 1.9 per cent.