The British Journal of Psychiatry
Types of alcoholic insanity

An important discussion on the above subject was held at the Boston Society of Psychiatry and Neurology, an account of which is published in the Journal of Nervous and Mental Disease for December, 1904. Dr. H. W. Mitchell of Boston introduced the discussion in a paper based on the study of 148 patients (excluding cases of true dipsomania which exhibited no insane symptoms) at the Danvers Hospital for the Insane, or 13 per cent of the male patients admitted. The cases were grouped as follows: delirium tremens, acute and subacute alcoholic hallucinations, delusional alcoholic insanity, and alcoholic dementia. Two were cases of Korsakoff's psychosis polyneuritica of alcoholic origin. He found that among cases of delirium tremens “ nearly all recovered without development of the graver forms of alcoholic insanity”. The prognosis in cases of acute alcoholic hallucination was good for the attack but relapses due to renewal of drinking habits were common. These cases were characterised by vivid auditory and visual hallucinations, the former predominating, with little disturbance of consciousness and with transitory delusions probably based upon the hallucinations. In the case of subacute alcoholism there were auditory, visual, olfactory, and tactile hallucinations, with more prolonged persistence of delusions. Periodic relapses were seen in these cases during their stay in hospital, the intervals between the attacks being periods of practically normal mental condition. Permanent mental deterioration and dementia were the ultimate goal of this class of cases. Alcoholic delusional insanity was the term used for cases showing a development of delusions somewhat resembling paranoia. In many cases the delusions are elaborated from hallucinations. “ Ideas of marital infidelity, poisoning, and persecution were most common in this class of cases.” A tendency to incurable chronicity was observed in many and only a small proportion of cases recovered. Alcoholic dementia comprised cases in which marked mental deterioration and decay of intelligence and morality were the predominant symptoms and this occurred as the result of many years of more or less continuous use of strong spirits. Permanent mental deterioration was observed in all the cases studied. Among the various alcoholic psychoses were seen many cases resembling general paralysis, the exact diagnosis being possible only after prolonged observation - weeks or months. 10 per cent of the total cases suffered occasionally from epileptiform convulsions, while suicidal attempts and acts of violence were common in all classes of cases - points of medico-legal interest. An alcoholic or an insane parentage was common and made the prognosis bad. Somatic and grandiose delusions with alteration of the sense of personal identity were unfavourable symptoms in delusional cases. In continuing the discussion Dr. Woodbury said that 90% of cases recovered from first attacks of delirium tremens. Dr. Philip O. Knapp said that in the wards and clinics of the Boston City Hospital cases of delirium tremens, hallucination, and alcoholic dementia were fairly common, while paranoid forms were quite rare. Dr. Mitchell, in reply, said that alcoholic pseudo-paresis resembling general paralysis was fairly common. Such patients had sluggish pupils which, however, reacted to light. Inequality of the pupils and failure of the reflex to light were found practically only in cases which had had syphilis. The delusional or paranoid cases in his series amounted to nearly one-fifth of the total. Parental intemperance was a common etiological factor. The milder forms of alcoholic psychosis occurred in early life frequently in association with habits of drinking. Alcoholic dementia showed itself in middle age or later and was the result of heavy and continuous drinking for many years.