Alcoholic Epilepsy.—Alcohol, and especially that combination of alcohol with oil of wormwood and aromatics known as absinthe, is capable of producing convulsive seizures resembling epilepsy. Certain forms of alcoholic convulsions can scarcely be distinguished from ordinary epilepsy. Acute alcoholism may be an exciting cause of the convulsive seizures in an epileptic. Alcoholic epilepsy is, however, peculiar to chronic alcoholism, and particularly in individuals in whom there is an hereditary tendency to nervous disorders. Once established, alcoholic epilepsy may continue even after the alcoholic habit has been discontinued. The attack is usually followed by marked mental disturbances. These vary from profound dulness to stupor or mania; they last from some hours to several days, and present the characters of similar conditions following non-alcoholic epileptic paroxysms.
C. PSYCHICALDERANGEMENTS.—Yet more important than the visceral and nervous lesions of chronic alcoholism are the indications which it affords of a progressive debasing influence upon the mind. The moral sense, the will, and the intellect are involved successively in a process of deterioration, which, manifesting itself only in part and by little at first, becomes after a time general and plain to all the world, and ends at length in ruin more complete and more hopeless than that of the body. Indeed, it not infrequently happens that while the general health appears to be good and the nervous system, save in transient disturbances of function, presents no evidence of the toxic action of alcohol upon its tissues, serious psychical disorders are established. The alcoholic subject develops propensities, otherwise latent, that tend to refer him to the criminal or the insane classes of society. The psychical debasement, of which these propensities are the outcome, is, like the alcohol habit itself, progressive. This fact cannot be too strongly insisted upon. Like the loss of vascular tone, the sclerosis, the steatosis which alcohol induces in the body, this mental deterioration is cumulative and destructive. It is to its psychical manifestations that alcoholism owes its chief importance, not only as a study in pathology, but also as a problem of the gravest moment in social science.
1.The Moral Sense.—Deterioration of the sense of moral obligation is among the earlier of the mental phenomena of alcoholism. The moral sense is perverted and enfeebled. Sentiments of honor, of dignity, of reputation, and of decency are no longer cherished or regarded. The amenities of social life and the proprieties of personal conduct are disregarded or set at naught. He who was punctilious, considerate, and thoughtful becomes negligent, selfish, and indifferent to sentiments of honor and emulation; he gives himself up to indulgences formerly considered unworthy; his reputation and that of his family are no longer matters of concern to him; respect for public opinion is replaced by cynicism. Little by little the conception of duty, of justice, of honor are lost to him, or if he regards them at all it is rather as subjects for idle and purposeless discussion than as motives to regulate his life. These changes are gradual and progressive, their evolution being largely influenced by the hereditary traits and previous moral culture of the individual. The deterioration of the sense of right, and the coincident exaltation of those passions which are normally under its control, lead to the commission of the crimes peculiar to the early period of alcoholism.Indifference is another characteristic of this period—indifference not incompatible with a selfishness of the most intense kind. The sense of obligation to the family is forgotten, and the responsibility of providing for and caring for others is unfelt. If the drunkard's own wants, and especially his craving for drink, are gratified, the necessities of those formerly dear fail to move him. The affections are not only enfeebled, but they are also perverted; not rarely they are replaced by aversion, disdain, and hatred. The individual who has been calm, reasonable, and patient becomes excitable, perverse, and intolerable of contradiction or opposition. Prone to acts of sudden violence, he becomes gloomy, taciturn, and preoccupied. He is disturbed by fixed tormenting ideas or by vague pursuing terrors. He thus becomes self-conscious, irritable, fault-finding, and easily provoked to passion. The character, after a time, undergoes still more decided change: alternations of indifference and irritability characterize his varying moods. After a time the joys and the sorrows of life alike fail to provoke real feeling. At length the confirmed sot manifests moral traits that are simply infantile; he laughs without motive, he weeps without cause.
2.The Will.—At the same time the will undergoes an enfeeblement even more marked. Except in paroxysms of transient excitement it is feeble and uncertain. The subject of chronic alcoholism scarcely knows his own mind under ordinary circumstances. Aware of his duties and his obligations, he is unable to discharge them. Especially does he lack the power to say No. Vacillation, indecision, and dependence upon others become characteristic traits. This loss of moral energy, combined with the loss of physical power brought about by continued and repeated excesses, begets at once a distaste for the ordinary occupations of life and an inability to perform them.
3.The Intellect.—Loss of intellectual power comes last. In some cases it shows itself only after the most prolonged excesses, when the body itself is becoming thoroughly broken down. Exceptionally, fitful intellectual power is curiously sustained to the last. The first evidence of intellectual failure consists in diminution of vivacity and readiness. The intellectual state is marked by apathy, obtuseness, and indifference; mental processes are performed slowly and with difficulty. This is perhaps one of the causes of the mental indolence characteristic of alcoholism. After a time the drunkard becomes timid, loses confidence in himself, and is unwilling to engage in enterprises demanding mental effort. Some tardiness of appreciation then shows itself; conversation becomes difficult; ideas are not spontaneous, but must be sought for; replies are not made with the usual promptness; it is difficult to arouse and fix the attention. The sense of self-respect is now lost, and it is almost impossible to make the subject comprehend his degradation. The intellectual deterioration becomes more and more marked. The memory fails little by little and becomes treacherous. Names and dates are recalled with difficulty. The conversation is interrupted by an inability to choose the proper words with precision, hence hesitancy, interruptions, and various forms of circumlocution. The power of argument and of reasoning is now much impaired, the judgment is uncertain, the association of ideas is inexact, and at length the intellectual degradation attains a degree that unfits the subject for the ordinary relations of life.
The above-described derangements of the viscera, of the nervous system, and of the mind are the morbid phenomena induced by long-continued excesses in alcohol. Whether merely functional or dependent upon recognizable anatomical lesions, they indicate pathological changes in the organism which are radical, and which under the influence of the continuously acting cause are progressive. Taken together, they constitute the condition known as chronic alcoholism. In view of the familiar experiences of every-day life, it is hardly necessary to repeat that these derangements are manifested in all degrees of intensity and in the most variable and complex combinations. The specific nature of chronic alcoholism is, in truth, due not to the derangements themselves, the greater number of which are such as we may encounter in morbid states not occasioned by alcoholic excesses, but to the combinations in which they occur in consequence of the action of the specific cause upon the organism as a whole. The prominence of particular symptoms or groups of symptoms in any given case is to be accounted for largely, if not wholly, by individual peculiarities.
Chronic alcoholism, however latent it may be, however sedulously concealed, warps the life of the individual in all its relations. In its advanced degrees it amounts to mental and physical dyscrasia. Between these extremes is every grade of incapacity and degradation. It is beyond the scope of this article to discuss the moral, social, or medico-legal bearings of this condition. Its purely medical relations are sufficiently obvious from what has gone before. It has been the writer's aim to make clear the existence and nature of the continuing condition.
It remains to describe certain other psychical disturbances which occur in chronic alcoholism, and which require separate consideration for the reason that they are accidental rather than essential, many cases running their course without their manifestation.
4.Alcoholic Delirium in General.—True alcoholic delirium, presenting the traits about to be described, is never the result of the direct primary action of alcohol upon the nervous system. Transient excesses produce acute alcoholism, drunkenness, which, varied as its manifestations are, differs essentially from that peculiar delirium which occurs only in individuals in whom the nervous system has undergone those nutritive changes that are brought about by prolonged alcoholic saturation.
The most striking peculiarity of this delirium relates to the hallucinations which attend it. These are almost invariably visual; occasionally they are also auditory. Their objects, whether men, animals, or things are in constant and unceasing motion, appearing and disappearing, coming and going, and changing from place to place with extreme rapidity. In this respect they differ from the hallucinations of other forms of delirium, of which the objects are fixed and more or less permanent. As a result of this peculiarity, the objects of alcoholic delirium are almost invariably multitudinous, as swarms of vermin, herds of animals, multitudes of demons, and the like.
A second peculiarity is the restlessness of the delirium. The patient is invariably uneasy, apprehensive, always on the alert, declaring that some calamity threatens him or that some evil is about to befall him. In consequence of these apprehensions even momentary repose is wanting. If he lies down for a moment, it is only to rise again and peer under the bedor into the corners, turning his head from side to side in search of some realization of the fears that torment him. This sense of apprehension impels the patient to hurry ever onward from place to place in search of the repose which he nowhere finds. It is increased to positive terror by the ever-varying and constantly-renewed hallucinations which torment him, and from which he seeks to escape, no matter how great the obstacles to be overcome.
A third peculiarity of alcoholic delirium is insomnia. This condition is of the must marked and stubborn character, even continuing for several days in succession.
5.Delirium Tremens.—This is the characteristic form of alcoholic delirium, and, as is indicated by the name, is invariably accompanied by tremor. It must be looked upon as an episode or epiphenomenon of chronic alcoholism. It is rare that even prolonged temporary excesses in persons ordinarily sober are followed by delirium tremens. Such excesses in the subjects of chronic alcoholism are, however, perhaps the most common cause of this condition. Orgies, especially when associated with venereal excesses, very frequently terminate in delirium tremens. Occasionally also, but much less frequently than was formerly supposed, the abrupt discontinuance of alcohol is followed by the outbreak. Other exciting causes are violent emotions, as anger or fright; hardships, such as prolonged hunger, over-exertion, or watching; acute maladies, as pneumonia, dysentery, erysipelas, the exanthemata, or rheumatism; finally, serious traumatisms, with or without great loss of blood. Delirium tremens usually occurs in those addicted to the abuse of spirits, less frequently in beer-drinkers, and comparatively rarely in those whose excesses have been restricted to wine. The attack does not, as a rule, begin abruptly; its prodromes usually consist in an exaggeration of the previously existing symptoms of chronic alcoholism. The patient complains of malaise, restlessness; he becomes depressed, morose, anxious without cause, apprehensive of some calamity, or he is more impatient and choleric than before. The ability to apply himself to his ordinary occupations is lost. He complains of vertigo, ringing in the ears; sleep is disturbed, or there is already insomnia. At the same time the stomach is deranged, appetite is lost, the tongue is covered with a thick yellowish-white fur, and there is constipation or diarrhœa. The period of prodromes may last from a few days to a week.
The outbreak is characterized by delirium, without, at least in the greater number of cases, absolute loss of consciousness. That is to say, it is possible by addressing the patient with energy or by strongly arousing his attention to interrupt the delirium and for a moment recall the patient to himself. In the graver cases, however, loss of consciousness appears to be complete. The subjective impression of the delirium, as recollected at the termination of the attack, is that of a sense of overwhelming confusion and inability to recollect or co-ordinate the ideas that were crowding upon the brain. The hallucinations, as has already been indicated, relate almost exclusively to the organ of sight, more rarely to the hearing; also, and exceptionally, to the other organs of sense. They are almost always either terrifying or repugnant. The objects of the hallucinations of the sight have already been described. They consist of animals, serpents, and monsters, which crowd into the apartment, comingusually toward the patient, disappearing in the walls, in the floor, under the bed, or among the bed-clothing. These visions are usually aggressive, threatening the patient, throwing themselves upon him, striking him, or tearing at his vitals. They are sometimes replaced by phantoms, spectres of the most horrible character, skeletons, death's-heads, or by flames which surround the patient and threaten to consume him. Sometimes the hallucinations relate to the daily occupation of the patient, and he pursues his tasks with a feverish and distressing anxiety. These hallucinations are almost invariably of the most fleeting, incoherent, and variable kind.
Auditory hallucinations occur usually in individuals of marked neurotic tendencies. They are apt to be more coherent than the hallucinations of vision, and are often of the nature of those which occur in the delirium of persecution. Sometimes they consist of cries, of chiding, of menacing voices, of the repetitions of obscene words and suggestions; sometimes they are cries of horror or the roars of animals, sometimes explosions or the discharge of firearms; or, again, they are terrifying threats. Hallucinations of taste and smell are much more rare, and occur in the subacute forms of delirium tremens. The patient complains of annoying odors or disagreeable tastes, either constantly present or upon the taking of food or drink. Disturbances of general sensibility show themselves in hallucinations in regard to sensations of pricking, burning, or tearing of the surface of the body, or of animals or vermin crawling over the patient. Hallucinations relating to the sexual instinct are far from rare. The hallucinations of every form are apt to be more frequent and more troublesome during the night than during the day.
Restlessness, fear, and anxiety are characteristic phenomena of delirium tremens. The patient is not only terrified by the imaginary objects which surround him, but often in their temporary absence he experiences an equal degree of fear for which he can assign no cause. It is to this condition of apprehension that is due the desire to escape from his present surroundings which is so characteristic of the delirium in question. Under its influence the patient occasionally commits acts of violence of the most serious kind. Sometimes the delirium is more quiet: the patient converses with individuals whom he supposes to surround him; he busies himself with his familiar occupations, giving orders, directing work, dictating letters, and arranging his affairs. At other times the delirium takes the form of apprehension of poisoning, and food and medicine are alike stubbornly refused.
The countenance, as a rule, is animated, the eyes brilliant and injected, the look fixed or peering, but always eager, or the expression may be haggard and agitated. The physiognomy, although largely influenced by the character of the delirium, may be said to be in most cases characteristic.
Sensation is usually impaired; especially is this true of sensibility to pain.
Tremor, although occasionally slight, may be said to be never wholly absent. Sometimes it affects the muscles of all parts of the body; more commonly it is limited to the hands, arms, tongue, and lips; less frequently it manifests itself in the lower extremities. Slight tremor may be increased by causing the patient to hold his hands extended with thefingers separated. The movements of the hands consist of rapid rhythmical oscillations of nearly equal extent and duration. The tongue is protruded with a rapid jerking movement, and withdrawn with equal suddenness. It shows fibrillar trembling. The trembling is increased by voluntary movement, and is ordinarily associated with some loss of motor power. The gait is often hesitating and awkward; movements of the upper extremities are executed with difficulty, and speech is irregular and interrupted. The motor disturbances are occasionally associated with choreiform movements or actual epileptic convulsions.
Insomnia is a constant condition. It usually persists throughout the attack, and occasionally proves troublesome for several weeks after convalescence is in other respects complete.
In the absence of pulmonary complications the respiration is not 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 aboutfalling 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.
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. Clouston47estimates 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.
47Clinical 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 beoccasional 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 chronicalcoholic delirium relates to marital infidelity.48The 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.
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.
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
491. 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,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.
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.
There are two forms of dipsomania—the essential and the symptomatic. Of these, the latter is the more frequent. Its consideration requires in this connection very few words. It manifests itself by an irresistible desire on the part of many insane people for alcohol. It occurs both inthe prodromic and in the fully-established periods of insanity. It is especially common in various forms of mania and in the prodromic periods of general paralysis. The dominating influence in essential dipsomania is heredity. Occasional causes may bring on particular attacks, but their influence is secondary. Dipsomania cannot be looked upon as a distinct recurrent affection in an otherwise healthy person. At some period in their lives, and often long before the occurrence of characteristic paroxysms, dipsomaniacs show peculiarities indicating defects of mental organization. Certain symptoms of dipsomania are often mistaken for its cause. Thus, dyspepsia is more frequently an effect than a cause of the alcoholic excesses. The despondency, irritability, restlessness, hysterical manifestations, and insomnia which precede the attack are not the cause of it: they are its earliest symptoms.
The affection usually begins insidiously and is progressive. As a rule, although not always, it begins in early adult life. The manifestations of this disease are essentially intermittent and paroxysmal, but the impulse to drink must be regarded as a symptom which may be replaced by other irresistible desires of an impulsive kind, such as lead to the commission and repetition of various crimes, as the gratification of other depraved appetites, robbery, or even homicide. The paroxysms are at first of short duration, and are followed by return to the previous regular and decent manner of life. They become, however, by degrees, more violent and more prolonged. At first lasting for a few days or a week, by and by they extend to periods of a month or six weeks, the attack wearing itself out, and recurring with a periodicity sometimes variable and sometimes constant. In the intervals of these attacks for a considerable time the patients very often lead sober, chaste, and useful lives. At length, however, evidences of permanent mental trouble are manifested, and the case settles into confirmed insanity. The attack is usually preceded by evidences of mental derangement; the patient becomes restless and irritable; sleep is irregular and unrefreshing; he complains of general malaise, and is anxious, troubled by vague apprehensions. He presently abandons his usual occupations and gives himself up to disordered impulses, among which alcoholic excesses are the most frequent and the most easily gratified. Sometimes the patient passes his time at taverns drinking with all comers; at others he shuts himself up in a chamber and gratifies his desire for drink to the most extreme degree alone. Dipsomaniacs not rarely leave their homes and associates without warning or explanation, and pass the period of the paroxysm among associates of the most disreputable character. The desire for drink is gratified at all costs, and not infrequently they return to their friends without money and without sufficient clothing, most of it having been sold or pawned in order to purchase drink. The paroxysm is succeeded by a period of more or less marked mental depression, during which the patient not rarely voluntarily seeks admission to some asylum.
The true nature of dipsomania is frequently overlooked. As a symptom of hereditary insanity it is in striking contrast with the habitual propensity to drink which occurs in the ordinary alcoholic subject. The latter seeks occasions to drink. He renews his excesses not intermittently, but habitually. If in consequence of disgrace or misfortune or under strong moral suasion he is for a time abstemious, it is only to renew and tocontinue his indulgence upon the first favorable occasion. On the contrary, the true dipsomaniac recognizes his malady and struggles against it. Even more: for a time he shows much skill in concealing it. He avoids occasions to drink, and, reproaching himself for his mad and unreasonable desire, seeks by every means to overcome his impulse to it. The ordinary drunkard may become insane because he drinks; the dipsomaniac drinks because he is insane.50
50Magnan,Le Progrès médical, 1884.
Dipsomaniacs are apt to manifest precocious or retarded intellectual development. They are from infancy or childhood especially prone to convulsive or other paroxysmal nervous phenomena. They are often choreic, often hysterical. This association with instability of the nervous system is related to the fact that dipsomania is more common in women than in men.