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ness. A state of drunkenness is usually caused by a large quantity of alcohol being taken in a short period of time, the amount necessary depending upon the degree of tolerance on the part of th individual. In such cases we are not dealing with a specific toxic disorder of alcoholic origin, but with a distinct reaction change in consequence of the presence of alcoholic excess. It is well known how delirium tremens arises when drink has been shut off and that it is always provoked by physical shock or some acute disease, especially pneumonia. The mental disturbances caused by alcohol are quite varied, and the chief difficulty lies not in the distinction between its immediate effect and insanity, but in the determination of the point at which the habitue has developed sufficiently a general or permanent disorder to justify the diagnosis of insanity. In the acute alcoholic intoxication with hallucinations we do not find any indications that the nervous system is directly damaged by alcohol or other toxic agents. Acute alcoholic hallucinosis, and especially Korsakow's psychosis, shows characteristic toxic organic symptoms, such as tremors, speech defect, neuritis, fever, and on the mental aspect disturbances in perception, disorientation, and other mental defect symptoms which have a decidedly organic outlook and point definitely to a disturbance of the function of the brain.

The following is a case of acute alcoholic hallucinosis or as more commonly called, acute alcoholic delusional insanity, and it is the type which is one of the most confusing in its differentiation.

Case I.-Male, admitted June 13, 1916, age 40, who has been a heavy drinker for many years and for the past five years has taken on an average one quart of whisky a day, has frequently been unconscious from drink, has come in conflict with his environment, and been fined and imprisoned for misdemeanors, but not until he continually had auditory hallucinations in which he heard voices talking to him which said, "I have killed your cousin-I am going to kill you," and not until his conduct was in accord with these words; when he requested the sheriff to lock him up for fear of physical violence; when he began to have false suspicions and false ideas about things and people in general; when he began to have established fixed ideas of persecution independent of his hallucinations, could we state that the patient could be placed in the category of the insane. Likewise from a medico-legal aspect you can at once appreciate the difference as far as the patient is concerned and likewise society, whether we are dealing with a case of simple alcoholic intoxication or one in which a man's mind has actually become deranged

in consequence of the excessive use of alcohol. Thus, as in this case when the misuse of alcohol has led to permanent perversion of the emotional status with fear, and to impairment of memory and judgment, and has resulted in positive delusions of a systematized paranoid trend, we can judge the responsibility from a legal aspect.

Case II.-Female, age 26, admitted July 6, 1916, who during childbirth four months previous passed suddenly into a state of acute delirium, probably from the result of hemorrhages and nephritic complications. Her consciousness was greatly impaired, there was disorientation as to time, place, and persons she did not have a clear conception of things about her, and was continually muttering in an incoherent jumble of past memories and hallucinatory images and with purposeless muscular movement. This description is one with which you are all familiar and represents a condition which at that time could not be considered as insanity. However, the patient could be properly pronounced insane when she became conscious of her relation to her environment, and knew perfectly well what she was doing, began to act from some preconceived motive, even though it was insane, and her restless psychomotor activity became of some purpose, and her delusional ideas bore some relation to actual events, as for instance, that she gave birth to twins when in fact she only had a single birth, and developed delusions of a persecutory character in which an actual situation was distorted, and the hallucinations were not such incoherent sensorial mixtures of real and imaginary things, but were based largely upon personal experiences, and the general reduction of consciousness of the mntal faculties were not as general as in the delirium. These differential points, though they are somewhat arbitrary, usually suffice for practical purposes for an early diagnosis in cases in which the physician is compelled to act. This patient while in a delirium of fever was not insane, but there eventuated an infection-exhaustion insanity in an individual predisposed to a psychosis.

A frequent error in a case in which a differentiation is quite simple is the mistaking of paranoid dementia praecox and when such symptoms as verbigeration, stereotypy, mannerisms, and negativism with progressive mental deterioration are present the diagnosis is most easy.

In true paranoia we have an entirely different clinical pieture. We do not find the marked change in the patient's emotional state and his manner is that of suspicion; his delusions slowly become more organized and elaborated. The true paranoiac never manifests profound mental deterioration and in fact

the chief reason that he shows any dementia at all is owing entirely to his delusions. He becomes self-centered in his ideas as though his thoughts were concentrated in a narrow channel.

In paranoid dementia praecox the delusions are not well connected, and the emotions are generally periods of excitement and depression. If the patient can be made to talk at all he will discuss his delusional ideas, freely and readily reveal their lack of system and later on may entirely forget his delusions, while in true paranoia there is no such tendency as they become progressively more and more fixed and systematized.

Case III.-Male, age 31, admitted June 24, 1916. The early history is negative and he was apparently a normal child. Graduated from high school and although he was 21 years of age at the time of graduation it was because he had to miss a year occasionally to help work on the farm. After the death of his mother he inherited a farm of 109 acres. Patient is a Dunkard and was always very devoted to his religion. At about the age of 25 he began to express ideas that he was to be a great religious leader. Began to assume the attire and attitude of a Divine leader. When asked why he conducted himself as he did, he replied, "Because I am to become a great religious leader and reform mankind." Later he would have periods when he would become morose and stubborn and a short time previous to his admission made a murderous assault upon a small child. With no other analysis of this case one would believe the case to be one of true religious paranoia, but upon further analysis it could be ascertained that the patient has and has had distinct auditory hallucinations of religious content. He would hold direct communication with the Divine Spirit and further than this he manifested, also as at the present time, an indifferent and apathetic emotional state, and would do silly and childish things. He frequently breaks out into nonsensical laughter and presents numerous mannerisms which you cannot see in the patient before us. Frequently he strokes his hand through his hair and makes facial gestures, finally he will look heavenward with eyes fixed and without winking for several moments. As I have emphasized above, these evidences of deterioration with the early appearance of hallucinations and frequent emotional anomalies speak for paranoid dementia rather than true paranoia.

There is probably no disease in the realm of psychiatry in which a failure to make an early correct diagnosis has brought about such an untold amount of danger and suffering, not only to the patient but to his family and friends, as paresis. Men with fortunes have suddenly been thrust into abject poverty by attempts to carry out their paretic delusional ideas; the inno

cent members of the family have been subjected to humiliation and shame when the father, a previously highly respected citizen citizen of his community, in the incipiency of his disease through intellectual impairment and judgment loss, commits some outrageous and atrocious crime against society. Consequently the responsibility falls upon the family physician to recognize these cases early and ward off such calamities, for the relatives and friends interpret the patient's conduct as acts of vice and sin.

It is a perfectly simple matter to recognize these cases when the intellectual enfeeblement and the charactristic neurological manifestations have already made their appearance, at which time the greatest damage that befalls the patient and family has alrady occurred. In these very early cases examination of the spinal fluid will present a well marked lymphocytosis, which will at once at least serve to differentiate this disease from the so-called functional insanity. The Wassermann, Noguchi, Colloidal Gold and other reactions render us additional aid in the diagnosis. Our experience has been that the greatest number of errors is in the mistaking the early paretic for the highly recoverable exalted type of the manic-depressive psychosis, while the differentiation from other possible conditions as alcohol, brain tumor, crebral syphilis, disseminated sclerosis, epilepsy and arteriosclerotic dementia is comparatively less frequent.

Case IV.-Female, age 25, admitted August 11, 1916. At the beginning of her illness was considered only nervous, excitable, and greatly in need of rest to recuperate from the effect of long nursing her sick husband, and it was not until 11 months later that the real gravity of the patient's mental state and the real cause of her underlying condition was appreciated and steps taken to inaugurate treatment in the right direction.

The family history is negative excepting that one aunt had an exophthalmic goiter. Patient was an eight-months' baby. In childhood and in early womanhood nothing specially abnormal was noted. She was always of a jovial disposition and had many friends. In school she was bright and learned easily. Married at the age of 18 and has never had any children or miscarriages. In September, 1915, patient had a nervous breakdown which was brought about by her previously having nursed her husband for several weeks. A stroke of paralysis in which his whole left side was affected. He was absolutely helpless and had to be lifted around and cared for like a child. He was a rather large man and weighed about 180 pounds. The husband's paralysis cleared up to such an extent at the expiration of six weeks that he was able to get about with a cane which he entirely discarded three weeks later, and he is today completely well and able to attend to his duties as a railroad clerk.

Husband states he has no knowledge of his ever having had syphilis nor has the patient herself ever had any external evidence of syphilitic lesion. At the time she nursed her husband she was under a very intense emotional strain as she assumed the entire responsibility of his care, looking after him both day and night. After she had become completely exhausted they engaged a trained nurse for several weeks.

The patient's psychosis practically dates from this time. She neglected her household work and manifested a complete change in her personality and disposition. She would walk about continually wringing her hands and staring at times into vacancy. Previously she had always been neat and clean and now became somewhat untidy. She would make suggestive remarks and at times become profane. Refused to take medicine and would not converse with or see her friends. At the time of her admission, 11 months later, patient presented dilated pupils which wre very sluggish in reaction to light but responded quite readily to accommodation (Argyll-Robertson pupil). The pupils were not irregular and movement of the eyes was normal. Slight enlargement of the right lobe of the thyroid. Laboratory examination of the spinal fluid gave a cell count of 112 per c.mm, a very strongly positive Wassermann with an absolute inhibition. with 1 c.c., strongly positive Noguchi, and a characteristic paretic Lange Colloidal Gold Curve. Blood also strongly positive.

On neurological examination no paralysis could be noted. Dynamometric measurements of upper extremities registered equally. No convulsions. Only very slight tremors were noted on continuous effort, as, for example, when patient was writing a long letter. Co-ordination of the upper extremities not decidedly disturbed. Patella reflexes bilaterally greatly dimin ished. Superficial reflexes, as the epigastric and abdominal reflex, present but not very active. Babinski phenomenon noted bilaterally which on the left side is retained and almost continuous for several moments. Sensory tests for pain, temperature, tactile sensibility present no gross abnormalities.

Mentally on examination on admission, patient presented the following: She would busy herself on the ward by moving about from place to place. At times she would sing and play the piano. Showed a marked tendency to joke and most frequently presented a radiant expression. No evidence of any hallucinations or illusions. Frequent fluctuation of the emo tional state. At one moment she would be happy and at the next she would cry and shed profuse tears. Memory was not grossly defective. Patient was capable of giving a fairly connected history of her life and memory as to ordinary school knowledge is well retained. Orientation was well retained. No

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