Intemperance and Dipsomania as Related to Insanity
Art. VII. ? :Author: Edward C. Mann, M.D.,
Medical Superintendent State Emigrant Insane Asylum, Ward’s Island, New York. Bead before the meeting of the “American Association for the Cure of Inebriates,” held at Hartford, Conn., Sept. 28, 1875.
In accepting an invitation to read a paper before you to-day, I do so fully conscious that most of the gentlemen composing this Association have had far greater opportunities for studying this speciality than I have enjoyed. I shall therefore briefly present the subject to you as it has appeared to me during my connection with the asylum which I have the honour to repre- sent. I think it impossible to estimate the complex influences that intemperance exerts upon the production of insanity, and different authorities differ very much in their opinion on this subject. All agree, however, that it is intimately connected with and is one of the main causes of insanity. Lord Shaftesbury, in his evidence before the Select Committee on Lunatics, in 1859, expressed his opinion that fifty per cent, of the cases admitted into English asylums are due to drink. This is a rather large estimate, but many superintendents of foreign asylums have estimated the admissions from intemperance at twenty-five per cent, or higher, including not only the proxi- mate but remote cause of the disease. This percentage will be largely increased if we take into account the great number of cases in which the intemperance of parents causes the insanity or idiocy of their offspring. I have traced intemperance as a cause in almost every case of general paralysis that has fallen under my notice, and others have observed the same thing. M. Lunier estimates that fifty per cent, of all the idiots and imbeciles to be found in the large cities of Europe have had parents who were notorious drunkards. Out of 350 insane patients admitted during two years at Charenton, in Europe, insanity was attributed to drink in 102 instances. I think, from my examination of the statistics of all the insane asylums, both here and in Europe, that it is not too much to say’ that fully one-fourth of all the admissions are due, either proximately or remotely, to intemperance.
I pass now to the consideration of dipsomania as a form of physical disease?as insanity.
Dipsomania has been aptly defined as ” an uncontrollable and intermittent impulse to take alcoholic stimulants, or any other agent, as opium, or haschisli, which causes intoxication? in short, a methomania.” We must distinguish between this and the physiological state in which the individual merely chooses to indulge in liquor to excess, rlhe great question of importance is to distinguish the two states or conditions, when the result, intemperance, is the same. We must observe whether there are symptoms in our patient which can be referred to primary disease of the nervous system. A* e must examine for hereditary influences, which, when present, lead us, of course, to suspect disease. Early development of the appetite for stimulants points in the same direction. ^ But the great diagnostic point attending the disease is the irresistible impulse by which the patient is impelled to gratify his morbid propensit}T, being, during the paroxysm, blind to all the highei emotions, and pursuing a course against wlucli reason and conscience alike rebel, it is frequently seen that these paioxysms are preceded by considerable disturbance of the nervous system. The patient perspires and is sleepless, uneasy and piostiated, and so craves some stimulant.
Between the paroxysms lie is different from a common drunkard in oftentimes disliking exceedingly all stimulants, and is then a useful member of society. Dipsomania has been described under three forms: acute, periodic, and clnonic. The acute form is the rarest, occurring only after exhausting diseases or excessive venereal indulgence. The periodic form is much more frequent, and is observed in persons who have suffered injury to the head or spine, females during pregnancy and at the catamenial period, and also in men whose brains are overworked. This form is frequently hereditary, and con- sequently proportionately difficult of cure. These patients may abstain for weeks and months from all stimulants, and may, during this interval, positively dislike them. At last, however, the patient becomes uneasy, listless, and depressed; is not inclined to apply his mind; and, final]}r, begins to drink, and continues until intoxicated. It is an interesting and rather remarkable fact, that with this class of cases, as Charles Lamb, in his “Confessions of a Drunkard,’ pertinently remarks, “to stop short of that measure which is sufficient to diaw on toipoi and sleep, the benumbing apoplectic sleep of the drunkard, is to have taken none at all. The pain of the self-denial is all one.” The patient continues this course for ten days,^ or perhaps a fortnight, and then bitterly regrets his fall. This often runs on, if not checked, into mania, and lapses into dementia. The last and most common is the chronic form ; ?and I have always found this to be the most incurable form of the disease, as the patients are incessantly under the irresistible desire for alcoholic stimulants. I think the latter class of cases require constant seclusion in an asylum if they wish to be free from intoxication, as a discharge or leave of absence is always followed by a repetition of the same acts. In a majority of cases of this nature we find hallucinations of sight and hearing, which oftentimes produce very painful moral impres- sions, and at times even great terror in the patient. Cases of delirium tremens are excluded in these remarks. These patients manifest confusion of thought, perversion of feelings,, suicidal tendencies, tremors of the facial muscles and tongue, anaesthesia of the extremities at times, and very often paralytic symptoms, going on to general paralysis. The subject of here- ditary metamorphosis of the diseases of the nervous system is of great importance in this connection. As a result of intem- perance in the progenitors, we find transmitted to the offspring allied but different forms of neurosis : it may be dipsomania,, epilepsy, chorea, or actual insanity, or a proclivity to crime. It is, at all events, an aptitude for some form or other of nervous disorder, the particular form being often determined by causes- subsequent to birth. The law of hereditary transmission applies equally to the victims of dipsomania as well as to the other insane classes, and is to be studied, I think, in three divisions, according as it is manifested. First, in predisposi- tion, or simple aptitude, the result of a defective organisation and a weakened or diseased nervous system, as a result of which the possessor is predisposed or has a tendency to seek for the relief obtained by alcoholic stimulants when labouring under jDhysical or mental depression ; second, in the latent state or germ of the disease ; and third, in the actually developed dis- ease. The first of these states, the predisposition or aptitude, being hereditary in a strong degree, is universally acknow- ledged to be the most difficult to eradicate, and requires the wisest sanitary conditions adapted to both mind and body. Most people doubt the existence of the second or latent state or germ of the disease, ignoring the law of progressive de- velopment, and such persons find it difficult to believe that dipsomania coming on in maturity, as a result of ill-health, mental shock, &c., may have originated in intemperance in the parent or grandparent. Yet this is a fact. One very impor- tant organic law, which should be universally understood in this connection, is, that morbid impulses and characteristics and traits may disappear in the second generation and break out with renewed intensity in the third, although a tendency or predisposition may be transmitted to the offspring, and, under good hygienic and other favourable circumstances, die out and fail to be transmitted any further. I have remarked in my experience with the insane, whether the exciting cause he intemperance or something else, that the cases most unlikely to recover are those where the insane temperament or diathesis is clearly manifested, and where the predisposition to disease is inherited. Such patients, although they may have lucid inter- vals, rarely if ever entirely recover. I think the insane im- pulses to drink, which overcome all the efforts of the individual who inherits a tendency in this direction, present the same indications for treatment as do the suicidal and homicidal impulses, namely, seclusion from society and the necessary restraint in an asylum.
I do not agree with that class of persons who hold that under all circumstances the dipsomaniac is to he treated as an invalid, with the utmost gentleness and forbearance, and then, with the strangest perversity, turn round and tell you that inebriety is no excuse for criminal actions, and line and imprison the un- liappy man who has been driven into the debauch by an irre- sistible craving for drink, when properly he should be regarded as insane, and should be sent to an inebriate asylum for treat- ment and cure. Our laws at present fail lamentably in pre- venting intemperance, and this is due in a great measure to the false view in which this disease is held by the judiciary. The different forms of dipsomania correspond in their manifestations, and oftentimes in their causes, to other cases of mental disease, and cannot properly, I think, be separated from them as regards the fact of the disease. Dipsomania often appears as a result of the same causes that operate in the production of other types of mental disease, such as ill-health, severe mental shock, blows on the head and spine, and sunstroke.
We are dealing in both cases with abnormal cerebration; in the one case associated with mania, melancholia, dementia, and idiocy ; and in the other, with a depraved alcoholic appetite ?an irresistible impulse which the mind seems powerless to control: an insane impulse, just as surely as a homicidal or a suicidal impulse is an insane impulse. I think that when our cerebral patholog’v, which is as yet in its infancy, becomes more generally understood, it will be found equally applicable to this as to other forms of insanity. The terrible insane craving for alcoholic stimulants is often the result of a lowered vitality or abnormal organic development of the nervous system that has descended from generation to generation, gaining in intensity, until it manifests itself by the complete loss of self- control and active inebriety in children and grandchildren after they once taste intoxicating liquors and indulge in them.
The blunted moral perception which so many inebriates exhibit, and which renders them peculiarly liable to a relapse after they leave an asylum, is to be regarded in the same light, I think, as the perverted moral sense in moral insanity. In every institution for the insane we find inmates who exhibit no obvious intellectual aberration or impairment, the moral faculties being deranged, while the intellectual faculties remain apparently in their normal condition. The manifesta- tions of moral insanity may be a simple perversion of some sentiment or propensity, under certain exciting causes; and I think this exactly comprehends cases of dipsomania with loss of self-control and perversion of the moral sense. The person, of course, is aware that the act is wrong in both instances, but the control which the intellect exercises over the moral sense is overborne by the superior force derived from disease. I have been told many times, by both insane patients and dipso- maniacs, that the feeling on the one hand to commit some insane deed, and on the other to give way to alcoholic appetite, was contemplated in both instances with horror and disgust, and at first successfully resisted, until at last, having steadily increased in strength, it bore down all opposition. What can be a more powerful argument in favour of the disease theory of dipsomania ?
Pathology of Inebriety.?The basis of our cerebral patho- logy is the fundamental principle that healthy mental function is dependent upon the proper nutrition, stimulation, and repose of the brain; and upon the processes of waste and reparation being regularly and properly maintained. We know that the cerebral cells are nourished by the proper and due supply of nutritive plasma from the blood, and that this is essential to healthy function ; and, indeed, the ultimate condition of mind with which we are now acquainted consists in the due nutrition, growth, and renovation of the brain-cells. If now we take into the system an amount of alcohol that causes the blood- plasma to convey to the brain-cells a noxious and poisonous, in place of a nutritive substance, stimulating the cells so as to hasten the progress of deca}^ and waste beyond the power of reparation and renovation, and impressing a patho- logical state on them, we must inevitably have resulting a change of healthy function, and a certain amount of disease induced. Owing to the abuse of alcohol, we have resulting a change in the chemical composition of the cerebral cells from the standard of health, which is the foundation of organic disease, as it prevents and interrupts healthy function. As a result of the overfilling of the cerebral vessels or hyperajmia of the brain from the long-continued use of alcohol, we have at first symptoms of irritation, due to increased excitability of the nerve-filaments and ganglion-cells of the brain. The symptoms of exhaustion and depression occurring at a later stage are due to lost excitability of the nerve-filaments and ganglion-cells of the brain, owing to a want of the proper supply of arterial oxygenated blood to them. This is caused by the excessive cerebral hyperemia, the escape of venous blood from the brain being obstructed; the result being that no new arterial blood can enter the capillaries. We may have apoplectiform or epileptiform attacks and paralysis occurring in the course of these cerebral hyperemias, and they may be due either to obstructed escape of venous blood or to secondary oedema of the brain, in which transudation of serum takes place into the perivascular spaces and interstitial tissue of the brain, with consequent anosmia.
We know comparatively little yet respecting the physiology and pathology of the nervous system; and consequently com- paratively little information lias been gained regarding the morbid changes that take place in the brain and its appendages, as a result of the abuse of alcohol. Such knowledge in this direction as we do possess shows that analogous changes take place in chronic alcoholism and chronic insanity?namely, atrophy and induration of the brain, and thickening and infiltration of the membranes. The nerve-cells have also been found to be the seat of granular degeneration in some instances, and some liistologists have claimed to have dis- covered fatty degeneration of the various brain elements. Respecting the latter changes, Dr J. Batty Tuke, of Edin- burgh, who is one of the most successful of modern investi- gators in the department of morbid cerebral histology, gives it as his opinion that the application of the various tests for oil will fail to detect the presence of the so-called ” free oil- globules” in the substance of the convolution, which he con- siders to be but the scattered debris of granular cells. Ac- cording to the great pathologist, Eokitansky, we find thickening and increase of volume of the pia mater and arachnoid, and permanent infiltration of the former and a varicose condition of its vessels, as a result of continued abuse of alcohol. As the state of the pia mater is unquestionably closely related to the higher functions of the brain, the latter must suffer more or less as the result of such an abnormal condition of the former. If there exist a permanently congested and thickened state of the pia mater, it is extremely probable that if it becomes suddenly turgid and hypereemic as a result of severe emotional disturbances, we shall have, resulting from the increased pressure on the brain, coma, epileptiform and apo- plectiform attacks, and other grave nervous symptoms. It is fair to conclude that in the majority of cases the first changes that occur are repeated attacks of active cerebral congestion, followed by chronic cerebral congestion and chronic cerebral meningitis; and that, as the disease assumes a chronic form, the brain takes on a secondary change and becomes ancemic, atro- phied, and indurated?a state allied to cirrhosis. In these cases of chronic meningitis, proceeding to atrophy and induration?of which I have seen quite a number?the prominent symptoms have been impairment of memory, dulness of intellect bor- dering on dementia, trembling of the limbs, tottering gait, hesitating, slurring speech, and other symptoms indicative of gradually progressing paralysis. In two cases of general paralysis due to drink, in which I made a post-mortem exami- nation, paying careful attention to the state of the brain and spinal cord, I found in both instances thickening and opacity of the membranes, with adherence to each other and to the brain, showing the existence of chronic meningitis. The brain was in both cases ancemic and indurated, and in one case there was dilatation of the lateral ventricles with considerable ?effusion. The spinal cord was atrophied and indurated, and there was considerable fluid in the spinal canal in one of the cases, and also at the base of the brain. Upon hardening the spinal cord and making thin sections, and employing carmine staining, to demonstrate the structural relation of the cord more clearly, I found, upon microscopical examination, that there was atrophy and loss of the nerve-elements of the pos- terior columns, with a new formation of connective tissue. In making autopsies, where the cause of death has been owing, directly or indirectly, to the abuse of alcohol, I have found cirrhosis of the liver, fatty and waxy liver, cancer of the liver, chronic Briglit’s disease, cancer of the stomach, and cancer of the bladder, and, in one case, a gummy tumour of the dura mater. It is doubtless true that in many cases we shall find upon examination no pathological changes in the brain that are demonstrable by existing knowledge and appliances; but I think we should rather doubt the quality of our resources of observation than doubt the existence of pathological changes in this most delicate, sensitive, and complex of all organs, when we have observed during life its functions to be obviously perverted, if not destroyed.
Treatment.?Having endeavoured to prove that dipsomania is a physical disease?that it is, in fact, a distinct type of in- sanity?I pass, in conclusion, to the consideration of the question of the care of inebriates. I am strongly opposed to inebriates being confined in insane asylums, as they are very numerous, rapidly increasing, and a troublesome class of patients, and are a disturbing element among insane patients. They need to “be in an asylum adapted in construction, location, and sur- roundings to tlieir special needs. Most of this class of patients do not think that tliey should be placed in an insane asylum, and do not adapt themselves to their position. They are constantly demanding privileges which cannot be granted, and chafe under the restraint which is imposed upon them. They do not assimilate readily and pleasantly with the other class of patients, but domineer over and ridicule them. They are fall of mischief when in an insane asylum, and interfere materially with proper discipline. Of course there are exceptions, but this is, I think, the general rule.
Dipsomania is more troublesome to manage than simple insanity, and requires, I think, more perfect discipline, both moral and physical, than the latter. In the treatment of inebriates we have primarily to build up and restore shattered constitutions and broken-down nervous systems. We have a class of patients to deal with whose digestive powers are weakened, whose appetite is impaired, whose muscular system is enfeebled, and whose generative function is often decayed; the blood is impoverished and the general nutrition disordered. They are indirectly predisposed to the acquisition of nearly all diseases, as they have, by long indulgence in alcohol, lessened the power of resisting their causes. We have to deal with the results of a toxic poison, which has resulted in more or less pathological change in the brain and nervous centres. We have also to deal at times with various complications proceed- ing from the abuse of alcohol, such as cirrhosis of the liver, gastritis, epilepsy, various forms of dyspepsia, and, in some cases, with Bright’s disease. We must place our patient under the most favourable hygienic influences, provide for him cheer- fid, tranquil, and pleasant surroundings, repress cerebral excitement, procure sleep for him, and we must also give him plenty of good, nourishing food and an abundance of fresh air and exercise. I believe that to this disease, as to insanity under other forms, the remarks of Sir James Coxe are equally applicable, that ” purgatives, hypnotics, anodynes, and tonics are useful auxiliaries; but a comfortable meal is the best of sedatives, and abundance of exercise the best of hypnotics. All remedial measures are, I think, inferior to wholesome exercise of body and mind in this disease. W e must piovide amusements of every kind, and encourage patients to woik. We must stimulate inertia, resist every kind of perverted feeling, and check morbid impulses ; and at last we may, if we exeicise a wise care and discrimination, restore our patients to their homes and to society, permanently cured.
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