Alcohol is the most common of all the causes of insanity. Clouston47 estimates that from 15 to 20 per cent. of the cases of mental disease may be put down to alcohol as a cause, wholly or in part. Those forms of insanity in the production of which alcohol is merely an occasional cause are not, however, properly included in the group of alcoholic insanities. Still less are we to include in this group cases of symptomatic dipsomania; that is to say, cases of insanity in which morbid impulse to drink constitutes a prominent symptom of the prodromic or fully-developed periods of various forms of mental disorder.
47 Clinical Lectures on Mental Diseases, Am. ed., 1884.
Alcoholic insanity manifests itself as an outcome of chronic alcoholism, just as epileptic and hysterical insanity show themselves as the outcomes of epilepsy and hysteria. This group properly includes various forms of mania-a-potu, especially the maniacal form of acute alcoholism, delirium tremens, and other transitory psychoses which occur in acute and chronic alcoholism.
In truth, the mental derangements of ordinary drunkenness constitute in many cases a form of transient insanity. These forms, have, however, already been considered at sufficient length. Dipsomania, for reasons already stated, cannot be regarded, either in its symptomatic form or in its essential form, as belonging to the group of alcoholic insanities.
a. Melancholia.—Melancholia is the most frequent form of true alcoholic insanity. It may begin abruptly or gradually, with changes of character, vague disquietude, great irritability, and disturbances of sleep amounting in many cases to insomnia. Hallucinations of hearing are characteristic. In this respect the morbid mental condition in question is in strong contrast with delirium tremens, in which the hallucinations are principally visual. The hallucinations of hearing usually consist of accusing or threatening voices. These voices inform the patient that he is to be poisoned, assassinated, murdered, or that outrages of all kinds are to be committed upon him; they accuse him of murder, of robbery, of rape, and of other shameful crimes. Præcordial distress is also apt to be present. In consequence of these hallucinations of hearing the patient falls into a profound melancholia, often characterized by suicidal impulses which are sometimes the direct outcome of hallucination, at other times blind and unreasoning. There is apt to be cephalalgia and insomnia. Trembling is not usually a marked symptom. Local anæsthesia and hyperæsthesia, if they occur, are transient. The ordinary duration of this form of alcoholic melancholia is much longer than that of delirium tremens, sometimes extending throughout several months. The termination usually is in recovery, less frequently in chronic delirium.
b. Mania.—This form of alcoholic insanity is characterized by various hallucinations which present peculiar characters. Thus, the hallucinations of vision commonly relate to supernatural apparitions, attended with luminous phenomena of various kinds. These visions may be occasional or they may be frequently repeated, or the hallucinations may consist of images of emperors, kings, princes, and potentates, or of military chieftains, in the midst of whom the patient passes his existence. Or, again, the hallucinations may be made up of historical scenes, pageants, the movements of armies, battles, and the coronations of kings, or they may be landscapes pleasant to the eye—snow-clad mountains, valleys filled with flowers, magnificent forests, and the like. These phantasmagoria are by no means fixed; on the contrary, they are of the most shifting character.
Auditory hallucinations are even more frequent, and quite as changeable. They bear a more or less well-defined relationship to the hallucinations of vision. They consist not rarely of promises of money, honors, titles, and the like. Sometimes they are voices from heaven, even the voice of God himself, commanding the patients to perform definite acts and promising in return equally definite blessings.
Hallucinations of general sensibility occur much less frequently. When present, they consist of various painful sensations, giving rise to the delusions of blows, stabs, bites of animals, electrical discharges, etc. In consequence of these hallucinations the delusions are often of a grandiose character. Patients believe themselves to be God, the pope, or some great potentate, or enormously rich, etc.
The somatic condition depends upon the degree of chronic alcoholism existing at the time of the manifestation of the mania. There are usually marked tremor, hesitation and uncertainty of speech, stubborn sleeplessness. Acute mania may show itself abruptly, attaining its full development in the course of a few days, or the development may be gradual. The prognosis in alcoholic mania is unfavorable; recoveries are rare. The fatal termination is sometimes the result of the maniacal condition itself, and sometimes the result of visceral complications. This form of insanity occasionally terminates in chronic delirium.
c. Chronic Delirium.—This form of alcoholic insanity is one of the terminations of acute alcoholic melancholia and of acute alcoholic mania. It is also one of the results of repeated attacks of delirium tremens. Finally, it may develop independently of these affections.