CHAPTER VIITHE 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 Britishasylums 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 musculartension. 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 paresisand 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 attributetheir 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 violenceare 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 patientimagining 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, terminatingin 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. Thisoccurred 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 inthe 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 ofpersecution. 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 recognizedas 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 withchronicdrinking 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 misidentifypersons. 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-sevenper 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.