disturbed, save as a result of the restlessness and physical effort
which sometimes quicken it. The same statement is true of the pulse.
The action of the heart is usually enfeebled, and the first sound
weak. The temperature is normal. The skin is frequently bathed in
copious perspiration. There is complete loss of appetite, and in most
cases inability to retain food. Thirst is constant, often tormenting.
The tongue is sometimes moist, and coated with thick white or yellow
fur; sometimes hard and dry, sometimes red. The urine is scanty,
dark-colored, and sedimentary. It occasionally shows traces of
albumen. Constipation is the rule.
The duration of delirium tremens is from three to seven, or even ten
or twelve, days. The course of the attack is paroxysmal or remittent.
The symptoms usually undergo some improvement during the day, only to
become more urgent at night. The periods of remission are occasionally
marked by transient slumber; the recovery by prolonged and deep sleep.
But this is by no means the rule. Several varieties of delirium
tremens have been described by writers upon the subject. These are—the
grave form, characterized by violence of the motor disturbances,
aggravated delirium, and gravity of the general condition; the febrile
form, in which after the third or fourth day the temperature, without
pulmonary or other discernible complications, suddenly rises to 104°
F. or beyond that point, with great aggravation of the general
symptoms; the adynamic form, marked by failing heart-power, feeble or
imperceptible pulse, profuse sweats, collapse, stupor, which deepens
into coma and ends in death; and finally, the subacute form. Here the
patient is quiet, but restless. The delirium scarcely passes beyond
the limits of occasional wandering, and relates chiefly to matters
connected with the daily interests and occupations of the patient.
Tremor is more or less marked, and sleeplessness is stubborn.
The termination of delirium tremens is in—1, recovery; 2, in death; 3,
in the chronic form; and 4, in other forms of insanity.
1. Recovery.—Except in the grave forms recovery may be said to be the
rule. Occasionally ushered in by a prolonged, almost critical, sleep,
more frequently it takes place by gradual improvement. In the latter
case the remissions are more and more prolonged, and attended by
increasing repose alike of body and of mind, and by tendency to sleep.
The hallucinations become feebler and less tormenting, at length
recurring only in the evening or at night, and especially as the
patient is about {630} falling asleep. The anxiety and restlessness
grow less urgent, consciousness becomes more secure, the trembling
diminishes, and recovery is slowly established. The tremor is apt to
persist some days into convalescence.
2. Death.—This mode of termination is not very common in the ordinary
forms of delirium tremens. In the grave forms it is usual, sometimes
occurring suddenly, sometimes gradually from intensification of the
symptoms and failure of nervous power; or it may occur in consequence
of pulmonary, cerebral, or renal complications; finally, the fatal
termination is often due to the acute disease or the traumatism by
which the delirium tremens has been excited, and of which it is, in
fact, a complication.
3. Chronic Delirium Tremens.—This mode of termination, described by
Lentz, is rare. The acute phenomena subside; the restlessness and the
mental agitation diminish. Insomnia gives place to sleep, which is
light and disturbed by dreams and nightmare; most of the
hallucinations lose their activity and frequency, and finally
disappear. The changing delirium settles into a fixed delirium of
persecution; the tremor, while it becomes fainter, persists, and the
condition is permanent.
4. Other Forms of Insanity.—This mode of termination has been studied
especially by Magnan, who has classified the cases of delirium tremens
into three different groups, according to their tendency to recover or
to the development of mental alienation. The first group includes
those cases which run a favorable course and terminate in complete
convalescence; the second group, those cases in which the
convalescence is prolonged and characterized by repeated relapses; the
third group is composed of cases which likewise show a strong tendency
to relapse, but in which the delirium continues after the other active
symptoms have subsided. This form shows itself most frequently among
the subjects of hereditary alcoholism. After repeated attacks the
delirium becomes chronic. Morbid mental phenomena replace or accompany
symptoms more directly referable to organic disturbances of the
nervous system. Tremor gradually diminishes and disappears, the
gastric symptoms subside, insomnia passes away, even hallucinations
disappear, or at all events become infrequent; but the delirium which
developed coincidently with these symptoms continues, and finally
becomes chronic, losing to a great extent its original characteristics
and constituting a form of insanity. Finally, dementia constitutes an
occasional mode of termination in delirium tremens. It does not often
develop immediately, although cases of this kind have been recorded.
More commonly, the alcoholic subject, losing little by little his
mental activity after each attack of delirium tremens, subsides by
degrees into absolute and irremediable dementia. Paretic dementia may
also develop after prolonged alcoholic excesses characterized by
repeated attacks of delirium tremens.
The anatomical lesions after death from delirium tremens shed no light
on the pathogenesis of the condition. Meningeal congestion, œdema of
the pia mater and of the cortical substance of the brain, scattered
minute extravasations of blood, and some augmentation of the
cerebro-spinal fluid have been observed. In the greater number of
cases no lesions whatever beyond those characteristic of chronic
alcoholism have been discovered.
{631} 6. _Alcoholic Insanity_.—Among the psychical derangements, it
remains to notice briefly the more prominent forms of insanity which
develop in the course of chronic alcoholism, in consequence either of
hereditary or of acquired morbid mental tendencies. These are—_a_,
melancholia; _b_, mania; _c_, chronic delirium; _d_, dementia; _e_,
paretic dementia.
Alcohol is the most common of all the causes of insanity. Clouston[47]
estimates that from 15 to 20 per cent. of the cases of mental disease
may be put down to alcohol as a cause, wholly or in part. Those forms
of insanity in the production of which alcohol is merely an occasional
cause are not, however, properly included in the group of alcoholic
insanities. Still less are we to include in this group cases of
symptomatic dipsomania; that is to say, cases of insanity in which
morbid impulse to drink constitutes a prominent symptom of the
prodromic or fully-developed periods of various forms of mental
disorder.
[Footnote 47: _Clinical Lectures on Mental Diseases_, Am. ed., 1884.]
Alcoholic insanity manifests itself as an outcome of chronic
alcoholism, just as epileptic and hysterical insanity show themselves
as the outcomes of epilepsy and hysteria. This group properly includes
various forms of mania-a-potu, especially the maniacal form of acute
alcoholism, delirium tremens, and other transitory psychoses which
occur in acute and chronic alcoholism.
In truth, the mental derangements of ordinary drunkenness constitute
in many cases a form of transient insanity. These forms, have,
however, already been considered at sufficient length. Dipsomania, for
reasons already stated, cannot be regarded, either in its symptomatic
form or in its essential form, as belonging to the group of alcoholic
insanities.
_a_. Melancholia.—Melancholia is the most frequent form of true
alcoholic insanity. It may begin abruptly or gradually, with changes
of character, vague disquietude, great irritability, and disturbances
of sleep amounting in many cases to insomnia. Hallucinations of
hearing are characteristic. In this respect the morbid mental
condition in question is in strong contrast with delirium tremens, in
which the hallucinations are principally visual. The hallucinations of
hearing usually consist of accusing or threatening voices. These
voices inform the patient that he is to be poisoned, assassinated,
murdered, or that outrages of all kinds are to be committed upon him;
they accuse him of murder, of robbery, of rape, and of other shameful
crimes. Præcordial distress is also apt to be present. In consequence
of these hallucinations of hearing the patient falls into a profound
melancholia, often characterized by suicidal impulses which are
sometimes the direct outcome of hallucination, at other times blind
and unreasoning. There is apt to be cephalalgia and insomnia.
Trembling is not usually a marked symptom. Local anæsthesia and
hyperæsthesia, if they occur, are transient. The ordinary duration of
this form of alcoholic melancholia is much longer than that of
delirium tremens, sometimes extending throughout several months. The
termination usually is in recovery, less frequently in chronic
delirium.
_b_. Mania.—This form of alcoholic insanity is characterized by
various hallucinations which present peculiar characters. Thus, the
hallucinations of vision commonly relate to supernatural apparitions,
attended with luminous phenomena of various kinds. These visions may
be {632} occasional or they may be frequently repeated, or the
hallucinations may consist of images of emperors, kings, princes, and
potentates, or of military chieftains, in the midst of whom the
patient passes his existence. Or, again, the hallucinations may be
made up of historical scenes, pageants, the movements of armies,
battles, and the coronations of kings, or they may be landscapes
pleasant to the eye—snow-clad mountains, valleys filled with flowers,
magnificent forests, and the like. These phantasmagoria are by no
means fixed; on the contrary, they are of the most shifting character.
Auditory hallucinations are even more frequent, and quite as
changeable. They bear a more or less well-defined relationship to the
hallucinations of vision. They consist not rarely of promises of
money, honors, titles, and the like. Sometimes they are voices from
heaven, even the voice of God himself, commanding the patients to
perform definite acts and promising in return equally definite
blessings.
Hallucinations of general sensibility occur much less frequently. When
present, they consist of various painful sensations, giving rise to
the delusions of blows, stabs, bites of animals, electrical
discharges, etc. In consequence of these hallucinations the delusions
are often of a grandiose character. Patients believe themselves to be
God, the pope, or some great potentate, or enormously rich, etc.
The somatic condition depends upon the degree of chronic alcoholism
existing at the time of the manifestation of the mania. There are
usually marked tremor, hesitation and uncertainty of speech, stubborn
sleeplessness. Acute mania may show itself abruptly, attaining its
full development in the course of a few days, or the development may
be gradual. The prognosis in alcoholic mania is unfavorable;
recoveries are rare. The fatal termination is sometimes the result of
the maniacal condition itself, and sometimes the result of visceral
complications. This form of insanity occasionally terminates in
chronic delirium.
_c_. Chronic Delirium.—This form of alcoholic insanity is one of the
terminations of acute alcoholic melancholia and of acute alcoholic
mania. It is also one of the results of repeated attacks of delirium
tremens. Finally, it may develop independently of these affections.
Developing independently, chronic delirium is usually of rapid
invasion, and is characterized by the prodromes common to the various
forms of alcoholic insanity—irritability, headache, vertigo, insomnia,
etc. Hallucinations of hearing are very common, and relate principally
to the sexual life of the patient. Voices taunt him with the fact that
he is maimed or impotent; he hears persons whispering that he is about
to be castrated or that he is the subject of loathsome venereal
diseases, or they declare that he is known to be addicted to vile
crimes and bestiality. Hallucinations of sight are much less common;
those of the other special senses occasionally occur. The delirium
takes the form of delusion of persecution. The patient believes
himself the object of plots and conspiracies; his enemies are seeking
to ruin his good name, to tarnish his reputation, to poison him. They
put filth in his food or charge him with electricity; they steal away
his vital force or his sexual power; they taunt him; they mock him;
they beat him and rob him.
A delusion so frequent as to be almost characteristic of chronic {633}
alcoholic delirium relates to marital infidelity.[48] The patients
cherish unjust and often absurd suspicions of the virtue of their
wives. These delusions arise independently of hallucinations either of
sight or hearing, and are of the greatest importance, because they
supply logical motives for the most appalling and brutal crimes.
[Footnote 48: “The combination of a delusion of mutilation of the
sexual organs with the delusion that the patient's food is poisoned,
and that his wife is unfaithful to him, may be considered to as nearly
demonstrate the existence of alcoholic insanity as any one group of
symptoms in mental pathology can prove anything” (Spitzka, _Insanity_,
N. Y., 1883).]
Alcoholic delirium differs in the transitory and incoherent character
of its delusions from ordinary chronic delirium, in which the
delusions are much more apt to be fixed and permanent.
_d_. Dementia.—This is a common terminal condition of alcoholism. It
may develop, without the intervention of other forms of mental
disease, in the course of chronic alcoholism as a mere intensification
of the intellectual and moral degradation of that condition. This is
especially liable to occur in hereditary alcoholism. Dementia also
closes the scene in a considerable proportion of cases characterized
by repeated attacks of delirium tremens. It likewise constitutes the
terminal condition in other forms of alcoholic insanity.
The symptoms are sometimes so slight as to escape ordinary
observation. More commonly they are fully developed. As compared with
ordinary dementia, they present but little that is characteristic.
Alcoholic dements are perhaps more filthy and more difficult to
manage, duller and more mischievous, than others. Their somatic
disorders are more marked. In them hyperæsthesias are replaced by
anæsthesias; sleep is apt to be irregular and disturbed; the
hallucinations characteristic of the antecedent alcoholic psychosis
now and then reappear. Slowly-developing failure of intellect,
forgetfulness, stupor, end in more or less complete loss of mental
power. Nevertheless, a small proportion of the milder cases are
capable of arrest under treatment.
_e_. Paretic Dementia.—Alcoholism is an important etiological factor
in the production of this condition. The intellectual disorders and
motor disturbances which characterize it, varied as they are, are
associated with cerebral lesions, and especially with lesions of the
cortex equally varied—lesions which are common in chronic alcoholism.
These lesions vary from meningeal congestion and inflammation to
profound inflammatory and degenerative alterations in the cerebral
substance.
Paretic dementia may develop after long-continued excesses without
previous appreciable mental or cerebral symptoms. In such cases it
presents no specific indications of its alcoholic origin. The
difficulty of determining the influence of alcohol in its causation is
increased by the fact that alcoholic excesses—symptomatic
dipsomania—are frequent in the prodromic and early stages of this form
of mental disease. Paretic dementia may also develop after repeated
attacks of delirium tremens. Here the early attacks end in recovery
apparently complete; later, the convalescence is unsatisfactory and
prolonged, leaving some indications of intellectual enfeeblement,
which, after renewed attacks, increases, and is accompanied by
delusions of grandeur, embarrassment of speech, unequal dilatation of
the pupils, and general paresis. The prognosis is practically
hopeless.
{634} III. Hereditary Alcoholism.
This term has been used in a somewhat vague manner to designate the
morbid tendencies and pathological conditions directly transmitted by
alcoholic subjects to their offspring. Chronic alcoholism on the part
of one or both parents may be followed by morbid manifestations in the
child. The hereditary transmission of the effects of alcoholism has
been recognized from remote antiquity. Aristotle believed that a woman
given to drunkenness would bear children with the same tendency.
Plutarch affirms that the children of drunkards will abandon
themselves to the same vice. Hippocrates speaks of the distressing
effects of drunkenness upon the product of conception. Bacon states
that many idiots and imbeciles are born of drunken parents. In more
recent times the fact has been generally recognized that many maladies
caused by the abuse of alcohol are liable to be transmitted to
succeeding generations, and that alcoholism may in this way, in the
course of two or three generations, lead to the complete extinction of
families. Alcoholism on the part of the parents certainly exerts an
unfavorable influence upon the health of their children, who are
especially disposed to cerebral congestion, hypochondriasis,
intellectual feebleness, and insanity. Two forms of hereditary
alcoholism have been recognized: First, that in which the disease or
defect of the parent is transmitted to the offspring; and second, that
in which the disease or defect is not directly transmitted to the
offspring, but a morbid tendency which manifests itself in diseases or
defects of a different kind.[49]
[Footnote 49: 1. Heredite de similitude, Alcoolisme hereditaire
homotype; 2. Heredite de transformation, Alcoolisme hereditaire
heterotype.]
1. The appetite for strong drink is frequently transmitted from
parents to the children, just as other traits of the mind or body.
Sometimes it develops early, sometimes late in life; as a rule,
however, this hereditary propensity shows itself at an early age, and
is apt to be intensified at the time of puberty and the menopause.
Objections have been urged against the theory of hereditary
alcoholism. Among these the strongest is perhaps that the taste for
drink in the offspring of alcoholic subjects is the result rather of
opportunity and example than of heredity. The frequency with which
alcoholic tendencies develop themselves in children reared and
educated away from their parents, and the number of cases in which
these tendencies show themselves only at an advanced period of life,
long after the influence of example in childhood has ceased,
sufficiently disprove this assumption. The hereditary influence does
not, however, invariably manifest itself in the desire for drink. On
the contrary, not rarely it consists in feebleness of nervous
constitution, characterized by irritability, want of mental repose, or
a restless or vicious disposition which demands constant excitement.
Hence such individuals, although intellectually well developed, are
often scarcely more than moral imbeciles, in whom the passion for
drink may be replaced by the opium habit, addiction to gaming and to
other vices, and whose career is shaped largely by an inordinate and
insatiable craving for excitement of all kinds. Hereditary alcoholism
follows the laws of heredity in general. The tendency may be
transmitted directly from one generation to another, {635} or may skip
one or more generations, taking in the intermediate periods some
different form.
2. The second variety is that in which the symptoms of chronic
alcoholism are manifested in the offspring in the absence of the
direct action of alcohol; that is to say, not the taste for alcohol,
but the results of the gratification of that taste are transmitted,
just as epileptic or hysterical patients may transmit to their
offspring epilepsy or hysteria; thus it is not rare to encounter in
the descendants of alcoholic parents perverted sensation, both general
and special, hyperæsthesia, anæsthesia, flying neuralgias which do not
always follow the course of particular nerves, but frequently affect
in a general way the head or the members or manifest themselves as
visceral neuralgias. These persons are much troubled with headache
from slight causes and with migraine. Nor are disturbances of vision
rare, nor vertigo. Insomnia is also frequent in such individuals, and
augments the other symptoms. Digestive troubles also frequently occur,
notwithstanding a regular and perfectly temperate life. Such persons
are often subject to hallucinations of sight and hearing, and are
liable to have delirium in trifling illnesses.
The second form of hereditary alcoholism manifests itself in a wholly
different manner. The descendants, without a special appetite for
strong drink, and in the absence of the special morbid manifestations
above described, are singularly liable to mental and nervous diseases
of various kinds. Among these convulsions and epilepsy are especially
frequent; hysteria and various forms of insanity also occur. In this
group of cases we find every degree of arrest of intellectual
development, from mere feeble-mindedness to complete idiocy. As
manifestations of the influence of alcoholism upon the offspring may
be cited certain moral peculiarities otherwise inexplicable, such as
are seen in children who at a very tender age show themselves
vindictive, passionate, and cruel, to whom the sufferings of others
afford pleasure, who torment their companions and torture their pets,
and show precocious vicious tendencies of all kinds. Later in life
these persons become lazy, intolerant of discipline, vagabonds,
unstable of character, without the power of application and without
moral sense. Given to drink, defiant of law, they constitute the great
body of tramps, paupers, and criminals. The children of alcoholic
subjects are often feeble and puny, pale, badly nourished, and
curiously subject to morbid influences.
IV. Dipsomania.
Dipsomania, which has also been described under the term oinomania, is
rather a form of insanity than of alcoholic disease. The
characteristic symptoms are, however, in the greater number of
instances, due to indulgence in alcohol. The subjects of this
affection usually belong to families in which insanity, and especially
this particular form of insanity, is hereditary.