less beset all. With each new giving away, the criminal impulses are stronger until eventually they are, as here, the ruling passion and their subject becomes the habitual criminal. To be sure, it may be argued that the habitual criminal is a phenomenon not found in the ranks of the normal, and that moral sense is so obviously defective as to entitle the habitual criminal to a certain amount of sympathy because of his lack of responsibility. Where, however, as in the majority of cases, the moral defect seems to be an acquirement of almost deliberate choice, where the will has been simply to follow the direction of impulse, it may be well to guard ourselves lest we fall easily into a mawkish sentimentality which makes a poor unfortunate out of the individual who, although he may have started with bad environment and a poor heredity, has been content, as in the case cited, to drift with the tide and resist no downward impulse.

This man seems to the writer to belong to the criminal class and not to be entitled to that preferment which he receives when classed as an imbecile. But the question may perhaps fairly be asked: Is he imbecile, criminal, or both?

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P. S. Under date of July 22, 1908, the superintendent of the State Asylum wrote that he did not, after careful observation, consider this case as a high-grade imbecile, but rather as a “psychopathic personality." His observation showed the man intensely selfish, cunning, deceitful, egotistical, cowardly." He had "organized an attempt at escape that came near being successful, and included hardened criminals serving long sentences. The frustration of their plans affected him the least of any engaged in it." Observation led to the conclusion that he was improperly confined in an asylum and that he belonged in prison. In September, 1908, he was discharged as "cured" and returned to the authorities of Wayne County. Here in jail he talked in abusive terms of the asylum, and on trial for larceny was discharged (October 15).

Some other misdemeanor will doubtless again soon bring him before the courts, when he should, for his own good and that of the community, be committed to prison for a maximum time. December, 1908, sees him again under arrest.

ALCOHOLIC PSYCHOSES IN HOSPITALS FOR THE

INSANE.*

BY JAMES M. KENISTON, M. D., MIDDLETOWN, CONN.

With the recent and increasing tendency to extend the frontiers of insanity, very many cases are now committed to hospitals for the insane, which formerly would have never, or seldom, been sent there. Take for example, infection and exhaustion psychoses, simple senile deterioration, imbecility, etc. Thus our hospitals are overcrowded.

Hence an important question which confronts us is: Should all cases of alcoholism be treated in hospitals for the insane? This question has not been finally settled. There is no doubt that many alcoholics develop a psychosis of some kind. Delirium tremens at once occurs to us and is now considered by all but a few physicians as a mental disorder, presenting deep clouding of consciousness, numerous and terrifying hallucinations and delusions, great fear, inability to control attention, great psychomotor unrest, besides the tremors, insomnia, anorexia and other physical symptoms. The course is rapid and the prognosis fairly good, at least for first attacks, with prompt and proper treatment. Cases of delirium tremens are being committed to this hospital' to a large extent during the past ten years, viz., seventy-five cases, six of whom were females. Cases are also being sent more and more freely to general hospitals, whereas twenty or more years ago they would have been treated at home, in police stations, jails, or, where such existed, in inebriate asylums.

Owing to the extreme fear, restlessness, defensive and protective movements attempts to escape from the threatening "horrors "-which often lead to assaults on the nurses and physicians, and the almost continuous outcries by night as well as by day, these patients are a very disturbing element, and unless

* Read at the sixty-fourth annual meeting of the American MedicoPsychological Association, Cincinnati, May 12, 1908.

1

Connecticut Hospital for Insane. Dr. Henry S. Noble, superintendent, has kindly given permission to use statistics.

proper means of isolation are available will upset the order of an entire ward.

In alcoholic delusional insanity and alcoholic paranoia, we find patients as a rule comparatively free from motor unrest, although brief exacerbations of excitement may occur. In these psychoses the fundamental symptoms are the delusions of persecution, infidelity or hostility, with hallucinations, almost invariably aural, while consciousness is clear, the train of thought is fairly relevant, the emotional affect is not in proportion to the delusional formation, and patients can and often will co-operate in treatment, as they have some insight as to the cause of their trouble.

During the past ten years there have been admitted to this hospital 170 cases of alcoholic delusional insanity, 19 of whom were women. During the same period there were admitted 167 cases of chronic alcoholism, 35 of whom were women. This psychosis, which practically forms the basis on which arise most, if not all, of the other alcoholic psychoses, is characterized by a gradually progressive deterioration, shown chiefly in impaired memory, lack of concentration, incapacity for production, faulty judgment, moral degeneration and blunted emotions. The ultimate dementia in cases which do not recover never reaches the extent and intensity of that characteristic of dementia præcox.

We have had a few cases of alcoholic paresis and Korssakow's psychosis. My object is not, however, to give the complete symptomatology and course of the alcoholic psychoses, but simply to call attention to their fundamental symptoms.

Alcohlic psychoses, classified as such, have only within a very few years been reported in the tables of our American hospitals; in fact, some hospitals do not now report them. They have been tabulated under the head of toxic insanity, or packed in with the cases of acute and chronic mania or melancholia, according to the predominance of certain psychomotor symptoms and emotional states. To-day, anyone with a fairly long experience, recognizes the fact that the psychoses induced by alcohol present a fairly typical clinical picture, taking into consideration not only the etiology and symptomatology, but the course, prognosis and treatment. Alcoholic abuse is associated with other causative factors in psychoses other than alcoholic, but for the purposes of this brief paper all such are excluded.

We will now proceed to a statistical study of the number of alcoholic psychoses admitted to the Connecticut Hospital for the Insane since the adoption of the Kraepelin classification, October I, 1898. Dr. A. R. Diefendorf, in a study of 2000 consecutive cases, found that 238 cases, or 11.90 per cent, were alcoholics.

From October 1, 1898, to September 30, 1907, there were admitted to this hospital 3893 cases, all of which were thoroughly examined, presented before our regular daily staff meetings, and criticized by the entire medical staff. All were carefully reviewed, and no case was tabulated until the diagnosis had been confirmed. The next tables gives the admissions of the alcoholic psychoses for the last nine years.

The percentage of total cases of " toxic insanity" admitted prior to October 1, 1898 (which included a few cases of morphinism),

'Kraepelin now substitutes two forms-acute alcoholic hallucinosis and alcoholic hallucinatory dementia-for this group.

to the total admissions for the same period, viz., 247 cases out of 8446, was 2.92+. While with the more modern resources in the way of examination, and the greater care now taken to procure a full and detailed history of cases, the percentage of alcoholic psychoses would perhaps have been greater prior to 1898, the writer is convinced that during the past decade there has been an actual, and not merely a relative, increase in the number of alcoholics committed to this hospital. This is shown by the following table in the order of classification:

40 52 47 39 56 48 48 53 56-439

I have been unable to study the statistics of American hospitals fully, but have derived some data from a few hospitals in New England. At Danvers, Mass., the total alcoholics admitted in 1903 was 54, and total admissions were 432; in 1904, 100 cases to 754 admissions; and in 1905, 73 cases to 514 admissions. This gives the yearly percentage of alcoholics to total admissions as 12.50 per cent in 1903; 13.26 per cent in 1904; and 14.20 per cent in 1905. Average for three years was 13.35+. At Bridgewater the per cent was 17.89+ for 1903 and 36.55 for 1904. These patients were all from the criminal class, which accounts for the excessively large ratio.

In Vermont, heretofore a prohibition State, we found the per cent to be 8.44, while in 1906 it was only 2.40+. At Westboro in two years (1905-6) there were 96 alcoholics in 874 total admissions-a percentage of 10.98+.

At Medfield the percentage of alcoholic psychoses to total admissions for four years (1902-6) was respectively 8.17+, 9.20+, 12.66 and 13.38+. Average for four years was 10.73+. The average at the Taunton Hospital for three years (1903-6) was 10.80 per cent.