Various tests have demonstrated the limited mental capacity of the chronic alcoholic. Will power is greatly reduced and fatigability increased. Memory and attention are affected and falsification of the past may occur. The patient learns nothing new and forgets the important things. All productive efficiency is gone and interest is lost. Weakness of judgment and loss of memory capacity lead to delusion formation. These often take the form of ideas of jealousy. Delusions of persecution, poisoning or grandeur may appear from time to time. Frequently there are genuine hallucinations. Some cases terminate finally in mental enfeeblement. Emotional changes are common in the chronic drinkers. The alcoholic humor is characteristic. The capacity for taking things seriously has been lost and there is a tendency to undue levity, often with a marked feeling of self-satisfaction. Some individuals, however, become moody, irritable or dull. Occasionally anxious states appear, frequently with suicidal attempts. One of the common symptoms of this condition is an extraordinary irritability after drinking. This leads to quarrels, assaults and violence. Consideration for others is completely lost. These attacks are often followed by remorse. A prominent and significant feature of the disease is the marked moral deterioration. All affection for family and children may be lost. Selfishness is pronounced and the patient spends all of his money for drink. Sexual excitement is sometimes an important symptom. With all of this there is a constant craving for alcohol. The patients have no insight into their condition and attribute their headache and tremors to overexertion, etc. They always deny using much alcohol and are absolutely untruthful on this subject. Overwork necessitates drinking, or it only happens after a death in the family, etc. Will power deteriorates rapidly. These individuals often commit crimes and come into conflict with the law. Gastritis, cirrhosis of the liver and numerous other diseases complicate the situation. Dizzy spells and headaches are common, as well as tremors of the tongue and fingers. Neurotic involvements are noted, with anesthesias, hyperesthesias, paresthesias, and muscular atrophies as well as speech defects. Epileptiform attacks are not infrequent in chronic alcoholism, and were found in ten per cent of Kraepelin's cases. His investigations showed that eleven per cent of the beer drinkers in Munich had convulsions. Combinations of epilepsy and hysterical manifestations with chronic alcoholism are not at all unusual. Rybakoff found a hereditary taint in 66.6 per cent of his cases while Moli reported only forty-seven per cent. Heredity was found to be a factor in thirty-seven per cent of Kraepelin's Heidelberg cases and in seventeen per cent of those at Munich. He describes various pathological findings in chronic alcoholism. Meningitis with hemorrhagic membranes is common. The convolutions are atrophied and the ependyma of the ventricles thickened. Pigmentary deposits similar to those of senility are found in the cells and vessel walls. There is an increase of both neuroglia cells and fibres. Hemorrhages are occasionally found in the central gray matter.
When the suspicions of the chronic alcoholic lead to well defined delusions Kraepelin speaks of "alcoholic jealousy" as constituting a distinct psychosis. The patient sees in almost everything evidences of infidelity on the part of his wife and is often inclined to question the legitimacy of his own children. Assaults and violence are frequent occurrences. Occasionally genuine hallucinations accompany this condition. Suicidal and homicidal attempts are not uncommon.
The onset of delirium tremens, first described by Thomas Sutton in 1813, is characterized by states of anxiety, fear, insomnia with disturbing dreams, sensory excitement, hyperesthesias, flashes of light, etc. The development usually is sudden, with a loss of attention, disturbance of apprehension, restlessness, distractibility, numerous hallucinations of the different senses, illusions, clouded states with disorientation, tremors and ataxia. Touch, pain and temperature sensations, according to Kraepelin, are undisturbed. The field of vision is sometimes narrowed. Recognition of colors is uncertain. There is a marked disturbance of the equilibrium, suggesting some lesion either of the eye muscles or of the labyrinth. A decided lengthening of the reaction time in associations has been shown by various observers. Sensory hallucinations are common. The ability to read correctly is entirely lost and what is read is meaningless. A paraphasic form of reading has been described by Bonhöffer. The attention cannot be held for any length of time. A dreamy clouded state is characteristic. Disorientation is usually complete in the severe cases. The hallucinations and illusions are very marked and sometimes even suggest moving pictures to the patient. Hallucinations of vision are more common than those of hearing. Peculiar skin sensations such as feelings of electricity are spoken of. Hallucinations may be induced by pressure on the eyeball and sometimes by suggestion. There is occasionally a confusional form of speech suggesting dementia praecox, with a tendency to coin new words and employ entirely meaningless terms. Although consciousness is not always entirely clouded, events transpire as in a dream, always confused by innumerable hallucinations. An occupation delirium is common, the patient imagining himself busy at his customary work. Delusional ideas regarding everything in his surroundings are frequent. Ideas of grandeur sometimes occur. Never, according to Bonhöffer, is there a complete disorientation as far as personality is concerned. The patient always knows who and what he is. Complete mental confusion is not the rule. Distractibility is usually very well developed. Bonhöffer found an inability to supply omitted words and syllables from well known phrases and memory for test words and numbers was impaired. Articles read are repeated with many changes and omissions. Memory for remote events is usually well preserved. Sometimes there is a falsification of the past. The mood is anxious, fearful, seldom irritable, at times actually humorous. Cheerfulness and fear of death occasionally alternate.
The course of the disease is characterized by great restlessness often with a tendency to talkativeness. There is, however, no flight of ideas or rhyming. Delusions of persecution occur in some cases. Anesthesias, hyperesthesias, paresthesias, hypalgesias and sensitiveness of nerves and muscles are noted. Romberg's sign is present in some instances. Speech is often ataxic and paraphasic, and in advanced eases entirely meaningless. Tremors of the tongue and fingers are very characteristic. Writing is very much affected as a result. Epileptiform convulsions sometimes occur. Rarely focal symptoms, facial paralysis and hemiplegia appear for a short time. Reflexes are increased and ankle clonus occasionally appears. Defective papillary reaction and unequal pupils may be found, with diplopia and muscular weakness. Sleep is seriously interfered with. Bodily weight is reduced and blood pressure lowered. The temperature is usually elevated and the pulse accelerated. Albumen and sometimes sugar is present in the urine. The delirium often stops as suddenly as it begins, terminating in sleep, the patient being clear when he wakes. The memory of events is not well retained on recovery. The delirium may, however, become chronic and last for months. Some cases terminate in a hallucinatory feeblemindedness. This is likely to occur in psychopathic individuals. Hallucinations of hearing are more common in such conditions. People read their thoughts and influence their minds. They are subjected to hypnotism and electricity. The delusional ideas may be of a sexual nature or grandiose in character. The mood may be anxious or irritable. Suicidal tendencies sometimes appear. Later a humorous trend is often noted. Tremors and other neurological symptoms sometimes occur. Bonhöffer found at autopsy a considerable fibre loss in the central convolutions, the cerebellum and the column of Goll. In the large pyramidal and motor cells of the anterior central convolution the processes were deeply stained. Some nuclear changes were noted and occasional cells destroyed. Nissl described a granular degeneration of the neurones with a prominence of the "unstainable" substance, together with a swelling and crumbling of the cell bodies. Alzheimer often found free nuclei near the apical processes. In the glia cells and vessel walls granular detritus was observed. Acute and chronic cell alterations are more common in old alcoholics. Pachymeningitis hemorrhagica is sometimes found. Kraepelin considers it very doubtful whether wine or beer drinking ever causes delirium tremens, whisky and gin being the etiological factors as a general rule.
Korsakow's psychosis was first described in 1887. This is characterized by a loss of memory, and falsification, with a marked tendency to disorientation, and is often due to chronic alcoholism. It is practically always accompanied by polyneuritic symptoms. According to Bonhöffer, it usually follows delirium tremens. This occurred in one-fourth of Kraepelin's cases. Occasionally it begins suddenly, but as a rule gradually, during the course of a chronic alcoholism. The patients frequently complain of dizziness, headaches and fainting spells. In the foreground of this affection is the impairment of memory. This is one of the characteristic features. The events of a few hours ago are completely forgotten. Disorientation appears next. This affects time more than anything else. The power of apprehension or perception is very markedly impaired (one-sixth of the normal in Kraepelin's cases) and the reaction time is greatly increased. He also found memory reduced to one-third or one-fourth of the normal on actual tests (repetition of words and syllables). Falsification of past events is also demonstrable. This often leads to elaborate delusion formations. The mood is usually anxious at first, later indifferent, dull, suspicious, irritable, in some eases cheerful and even humorous. The methods of life are completely changed. The patients neglect themselves, lie in bed, etc. The physical signs are those of neuritis. Muscular pains in the limbs appear, with evidences of loss of power. Paraplegias and weakness of the grip are found. Romberg's sign is frequently present. Anesthesias, hyperesthesias or paresthesias are noted. The reflexes are usually decreased, rarely increased. Ataxia and other difficulties of gait are common. The pulse is usually slower as a result of involvement of the vagus. Speech difficulty, writing defects, facial paralyses, weakness of the eye muscles, with inequality and inactivity of the pupils, are to be expected. There are usually tremors of the fingers. Epileptiform convulsions are not infrequent. Aphasia, agraphia, apraxia, monoplegia, hemiplegic, etc., are observed in many cases. Physical disturbances of various kinds due to chronic alcoholism are also present.
At autopsy acute and grave alterations are found in the cells of the second and third layers of the cortex. A granular degeneration (Körnig Zellerkrankung) of the cells is also referred to by Nissl. There is some fibre loss in the central convolutions and the internal capsule, as well as in the columns of Goll. Hemorrhages and thromboses are to be found. Alzheimer found encephalitic foci with proliferation of the cells of the vessel walls sending out fibroblasts in the neighborhood, and a destruction of the nerve fibres. These foci are found in the central gray matter of the third ventricle, roof of the aqueduct, etc. There is a formation of new vessels and an outwandering of cells often accompanied by numerous hemorrhages into the gray matter around the aqueduct of Sylvius. Wernieke has described this process as an "acute hemorrhagic polioencephalitis superior" and finds it very commonly associated with Korsakow's psychosis. It occurs, however, in other chronic alcoholic conditions. The peripheral nerves also show a polyneuritis. Bonhöffer found Korsakow's psychosis in three per cent of his delirious cases. Thirty-three per cent of Kraepelin's cases were women and only 24.5 per cent were under forty years of age. Chotzen found Korsakow's psychosis in three per cent of his male and in twenty-one per cent of his female alcoholics.
The acute alcoholic hallucinoses as described by Kraepelin are characterized by well defined delusions of persecution and above all by hallucinations of hearing, with a clear sensorium. In eighty per cent of the cases the symptoms appear suddenly. Sometimes there is first an abortive delirious attack. Usually a multiplicity of hallucinations of hearing develop early. The patient hears threats and abusive language, always directed against himself. Visual hallucinations also occur, particularly at night. The other sensory fields are often involved. At the same time well marked delusions manifest themselves. These suggest every possible variety of persecution. Ideas of grandeur are sometimes observed. All of these symptoms are worse at night as a rule. Consciousness is usually fairly clear, and there is no disorientation. There is often a mixture of anxiety and humor. Some cases, however, are irritable and suspicious. Occasionally suicidal tendencies appear. Conduct is usually not greatly disturbed and the patient continues with his regular occupation. There is considerable insomnia and a tendency to run around a great deal and act foolishly at times. Physically, evidences of chronic alcoholism are always to be found. The customary duration of these acute conditions is from three to eight weeks, although they sometimes last for months. In a quarter of Kraepelin's cases the termination was in deterioration. There is a strong tendency to recurrence. The unrecovered cases are suspicious, surly, quarrelsome and have hallucinations of hearing. This condition may last for years. There are always occasional persecutory ideas. One-fifth of Kraepelin's cases became chronic. Bonhöffer described a paranoid type of long duration. The hallucinoses appear usually earlier in life than Korsakow's psychosis but later than delirium tremens. In Kraepelin's experience delirium tremens is three times as common as are hallucinoses. He looks upon these two conditions, however, as different clinical manifestations of "one and the same" disease process.
Alcoholic paralysis, so called, is a mixture of chronic alcoholic symptoms with those of general paresis. There is a mental deterioration with ideas of grandeur, emotional dulness, hallucinations, delusions of jealousy, speech defect, tremors and polyneuritis. Epileptiform attacks are frequent. Most of these forms according to Kraepelin belong to Korsakow's psychosis or polioencephalitis hemorrhagica superior. Alcoholic conditions may also be complicated by syphilis or arteriosclerosis.
Since the alcoholic psychoses have been generally recognized as such, there has been comparatively little difference of opinion as to their differentiation. The classification of the American Psychiatric Association is as follows:—
"The diagnosis of alcoholic psychosis should be restricted to those mental disorders arising, with few exceptions, in connection with chronic drinking and presenting fairly well defined symptom-pictures. One must guard against making the alcoholic group too inclusive. Overindulgence in alcohol is often found to be merely a symptom of another psychosis, or at any rate may be incidental to another psychosis, such as general paralysis, manic-depressive insanity, dementia praecox, epilepsy, etc. The cases to be regarded as alcoholic psychoses which do not result from chronic drinking are the episodic attacks in some psychopathic personalities, the dipsomanias (the true periodic drinkers) and pathological intoxication, any of which may develop as the result of a single imbibition or a relatively short spree.