CHAPTER VII
THE ALCOHOLIC PSYCHOSES
According to Tuke,[213] one of the oldest of the Egyptian papyri in the British Museum (Papyrus Sallier I) makes the following very interesting reference to alcoholism:— "Whereas it has been told me that thou hast forsaken books, and devoted thyself to pleasure; that thou goest from tavern to tavern, smelling of beer, at the time of evening. If beer gets into a man it overcomes his mind.... Thou knowest that wine is an abomination, that thou hast taken an oath that thou wouldst not put liquor into thee. Hast thou forgotten thy resolution?" It is difficult to realize that this refers to one of the earliest periods of recorded history. Hebrew, Greek and Roman literature are prolific in equally significant testimonials to the antiquity of alcohol as an intoxicant. It was referred to at considerable length by Aristotle, Plutarch and Hippocrates. That Haslam appreciated the important relation existing between alcoholism and mental disorders is shown by the following comment on this subject written in 1808:—"Thus a man is permitted slowly to poison and destroy himself; to produce a state of irritation, which disqualifies him from any of the useful purposes of life; to squander his property among the most worthless and abandoned; to communicate a loathsome and disgraceful disease to a virtuous wife; to leave an innocent and helpless family to the meagre protection of the parish. If it be possible the law ought to define the circumstances under which it becomes justifiable to restrain a human being from effecting his own destruction, and involving his family in misery and ruin. When a man suddenly bursts through the barriers of established opinion; if he attempts to strangle himself with a cord, to divide his large blood vessels with a knife, or swallow a vial full of laudanum, no one entertains any doubt about his being a proper subject for the superintendence of keepers; but he is allowed, without control, by a gradual process, to undermine the fabric of his health and destroy the property of his family."
Curiously enough the word alcohol is of Arabic origin and was employed originally to describe a powder used in applications to the eyebrows for cosmetic purposes. It was subsequently used for centuries as referring to a fine powder of any kind, as is shown by the writings of Paracelsus and others. The chemical composition of alcohol was not known until 1808, when it was described by Lavoisier. On the other hand, Salvatori in 1817 and Hufeland in 1818 referred to dipsomania as a disorder due to alcoholism. Esquirol, Trélat and other early writers included it in the "partial" insanities. Morel described it as an impulsive form of "délire émotif" and looked upon it as an hereditary condition. It has been classified with the periodical insanities and even as a form of melancholia. Magnan saw in it an episode of the insanity of degeneracy. Magnus Huss was responsible for the introduction of the term "chronic alcoholism" as descriptive of a pathological condition in 1852.
It is said that Caelius Aurelianus protested against the use of intoxicants in the treatment of the insane. Notwithstanding this early reference to a question of such importance, and the inauguration of the great temperance crusade which began in 1808, it has been shown by Tuke[214] that alcoholic beverages were issued in a routine way to patients and employees of the British asylums for the insane less than forty years ago. "Thirty superintendents hold that they have observed very beneficial results from the course pursued. The improvement usually refers not only to the patients, but to the discipline of the asylum." The cost of beer supplied to the inmates at the Glamorgan Asylum at one time was reported to be as high as two hundred and sixty pounds per year (Tuke). Beer was not discontinued as a regular article of diet for patients at the Derby Asylum until 1884.
In 1844 Flemming[215] in his classification of psychoses mentioned the following forms of alcoholic insanity:— Ferocitas et morositas ebriosorum, anoësia e potu, anoësia semisomnis, delirium tremens, and mania à potu. Clouston[216] described acute and chronic forms—mania à potu, dipsomania, alcoholic dementia and degeneration. Krafft-Ebing[217] speaks of hallucinations of the inebriate, delirium tremens, alcoholic melancholia, mania gravis potatorum, hallucinatory insanity, alcoholic paranoia, alcoholic paralysis and epilepsy. Delirium tremens he ascribes either to repeated excesses (à potu nimio), abstinence (à potu intermisso), insufficient nourishment, violent emotions, pneumonia and other acute diseases, loss of sleep, injuries such as fractures, etc. By hallucination of the inebriate (sensuum fallacia ebriosa) he refers to the transitory hallucinations of the constant drinker. Meyer[218] has described an alcoholic constitution "as shown by the lachrymose, prevaricating, jealous deterioration of the drinker."
Stöcker,[219] after an extended study of a considerable number of cases, came to the conclusion that alcoholism is the result of a constitutional condition but not the cause of characteristic psychoses. Often, as was also shown by Bonhöffer, it is to be attributed to a psychopathic personality either acquired or congenital. The psychoses represented by the group of patients he examined included manic-depressive insanity, dementia praecox, hysteria, epilepsy and other miscellaneous conditions. He refers to dipsomania as an epileptic equivalent. His conclusions in brief were as follows:—"Chronic alcoholism in the first place is a symptom of a mental disease. It may, however, so exaggerate stationary epilepsy, chronic mania, dementia praecox, etc., which hitherto were latent, and perhaps would remain still latent without alcoholic abuses, that it may lead to a sudden outbreak of a turbulent disease manifestation. It may also give these diseases peculiar traits or a peculiar coloring for some time, which above all, may appear as the most striking phenomena, and thus cover up the symptoms of the fundamental disorder. Furthermore, it may, also, on the basis of this constitutional disease give rise to independent clinical pictures." Karpas[220] in commenting on this says: "One must remember that cravings play important rôles in our mental life. Some of our cravings are gratified; others find realization in our dreams; still others are repressed and compensated. In fact, our mental life is nothing but a readjustment, of complex reactions. The poet finds recourse in his phantasies; the philosopher gives vent to his theoretical speculations; the scientist resorts to his inventions and hypothetical theories; the well balanced, normal individual seeks readjustment in healthy activities,—art, literature, science, occupations, sport, etc., etc. But the individual with a poorly endowed constitution finds refuge in neurosis, psychosis, alcoholism, drugs, and other vicious habits. We must recognize that alcoholism is nothing but a compensation for a complex, the fulfillment of which was denied by reality."
Kraepelin[221] described acute and chronic alcoholism, pathological intoxication, alcoholic jealousy, delirium tremens, Korsakow's psychosis, alcoholic hallucinoses, paralysis and pseudo-paresis. In acute intoxication Kraepelin finds an inhibition of apprehension, mental grasp and the elaboration of outer impressions with a stimulation of the release of volitional impulses. A clouding of consciousness develops, associated with emotional excitement and a weakness of will power. Perception and mental reactions are delayed and their accuracy decreased on mental tests. The discrimination between louder sounds is uncertain, although the sensitiveness to lighter sound impressions is increased as in the ether narcosis. Busch found a limitation of the field of vision. The preservation of memory impressions is imperfect. A solution of mathematical problems shows a lowered mental capacity for work. The association of ideas and composition of sentences is delayed. There is a tendency to new word formation, phrasing and rhyming, with a certain amount of distractibility. Goal ideas are often missed, and consistent, orderly thought is not possible. Expression is rapid and impulsive, and is often characterized by a loud tone of voice.
After larger amounts of alcohol psychomotor activities are interfered with as shown by the writing, and ataxia appears. The reflexes show an increased muscular tension. Physical strength is markedly lowered, although it may be increased for a very short time. Alcohol even in small amounts interferes with productive mental processes. Ideas lose in clearness and sharpness, fatigue occurs earlier and efficiency and judgment are impaired. Still larger amounts retard apprehension and comprehension and the intoxicated person no longer knows what is said to him. All ability to control his conduct is lost. There is a tendency to repetition in speech, rhyming and jargon. Capacity for mental work is finally entirely gone and memory becomes confused. Psychomotor stimulation and excitement appear early, terminating finally in weakness. Emotional trends, at first happy and cheerful, are usually irritable, later with outbursts of anger. Sexual excitement often appears. Various physical disturbances have been described.
In the pathological or complicated intoxications as described by Kraepelin, unusual emotional disturbances such as violent excitements occur. Anger or anxiety may develop with a clouding of the consciousness, and lead to uncontrollable rages with impulses to assault and kill. The most marked excitements occur in epileptics. The outburst is usually sudden in these cases and is followed by the most senseless and unjustifiable acts. Occasionally suicide is the result. In hysterical and psychopathic individuals alcohol may cause serious emotional disturbances, with clouding of consciousness or even delusion formation. Chronic drinkers are very likely to have abnormal symptoms at times. They often show a marked irritability followed by a pathetic and tearful mood. Abusive treatment of members of the family, jealousy, threats and violence are not uncommon. Delirious or anxious states with persecutory ideas and hallucinations are sometimes observed. These may exist only during intoxication. Alcohol often produces extreme excitements in cases of manic-depressive insanity, general paresis and dementia praecox. Pathological changes of various kinds have been reported. In acute alcoholism Nissl found a destruction of cortical cells in some cases and a disappearance of the stainable lumps in others. The nuclei of the neurones were shrunken and sometimes displaced.