The episodic accidents of chronic alcoholism are of four kinds: delirium tremens, acute hallucinosis, delusional states, and the polyneuritic psychosis.

The prodromata consist in an accentuation of the symptoms of chronic alcoholism. Sleep is more than ever disturbed by nightmares, preceded by painful hypnagogic hallucinations, and reduced in the last days before the attack to a vague somnolence. Violent headaches and a sort of inexplicable uneasiness usher in a grave affection.

Psychic Symptoms

These were admirably analyzed years ago by Lasegue and more recently by Wernicke. Three chief symptoms dominate the scene: disorder of consciousness, hallucinatory delirium, and motor excitement.

The disorder of consciousness involves exclusively the notion of the external world, i.e., allopsychic orientation, leaving intact the notion of personality, i.e., autopsychic orientation (Wernicke).

Illusions and hallucinations are constant and at times incessant. They present two general characteristics: (1) they are painful; (2) they are combined in such a manner as to form complete scenes and create around the patient a whole imaginary and often fantastic world. They affect all the senses, but the most interesting among them are those of vision and general sensibility.

en Autriche et en France. Bullet, de la soc. de med. ment. de Belg., 1895. - By the same author. L'assistance des alcooliques en Suisse it en Allemagne. Ibid. - Also. L'Asile d'alcooliques de departement de la Seine. Ann. med. psych., 1895, Nov.-Dec.

The visions of delirium tremens are always mobile and animated. They form an uninterrupted succession of strange, painful, or terrifying scenes. At the same time that the patient has visions of assassins or ferocious and horrible animals, he feels their blows, bites, or their repulsive contact: the murderer's dagger or the fangs of dogs or tigers sink into his flesh, spiders run over his face, and snakes slip and crawl under his clothes.

Two principal forms of delirium may be distinguished: (a) occupation delirium, and (6) persecutory delirium.

(A) Occupation Delirium

The patient imagines that he is amongst familiar surroundings and at his usual occupation. The hallucinations possess remarkable distinctness and intensity: the cab driver leads his horses, urges them on, whips them, and runs over pedestrians who do not get out of his way quickly; the cafe waiter waits upon guests, receives money, shows them to vacant seats. Like the dreams of the alcoholic this occupation delirium is generally of a painful character.

(6) Persecutory Delirium

The psycho-sensory disorders assume a terrifying character. Grimacing and horrible forms are seen in the folds of the curtains, on the window-panes, or on the walls. Assassins come out of every corner; the patient hears clearly their threats and abuses and describes their costumes and their weapons. He sees frightful and fantastic animals; rats, snakes, gigantic tigers fill the room, constantly changing their shapes and throwing themselves upon the wretched subject, who repels them with desperate efforts. An odor of poison proceeds from all sides; the food has a putrid taste.

The motor excitement is at times very violent. The patient walks to and fro in the dormitory or in his room, seeks his clothes, strikes the walls to open a passageway for his escape, emits cries of terror; or he whistles and sings, assuming in the intervals a conversational tone, as he imagines himself surrounded by his acquaintances. The movements, though sudden and awkward, always have a psychic origin (Wernicke); it is true that they are determined by imaginary representations and sensations, but they invariably present the character of purposeful acts. The patient who believes himself to be in his workshop goes through the regular movements necessary for the performance of his habitual work; another, the victim of terrifying hallucinations, executes the movements of flight or of defense.

On viewing broadly all the preceding symptoms we observe that the hallucinations of delirium tremens are like a dream in action. Just as a sleeper can be roused so can the patient be momentarily roused from his delirium by a sudden interpellation. One then obtains correct responses, so that the patient may create the impression of a normal person. But as soon as he is left alone he relapses into his delirium and agitation.

Physical Symptoms

The tremor of chronic alcoholism becomes exaggerated so that there is a shaking of the entire body.

The speech presents a characteristic tremulousness.

At times a slight degree of syllabic stuttering, paraphasia, facial paresis, or even hemiparesis appears, showing the participation of the projection centers in the morbid process.

The tendon and cutaneous reflexes are usually exaggerated.

A certain degree of hyperesthesia is the rule. The morbid irritability of the psycho-sensory centers explains the facility with which it is possible, by a simple suggestion or by slight mechanical stimulation, to bring forth a hallucination, even after the spontaneous psycho-sensory disorders have disappeared (induced hallucinations of Liepmann).1

We encounter also paresthesias and even anaesthesias.

Fever is almost a constant symptom; its presence furnishes an excellent element for prognosis. In favorable cases the temperature does not rise beyond 39° C, reaching its maximum towards the end of the second day. Defervescence takes place either rapidly or by lysis. In grave cases the temperature rises above 39° or even 40° C.

1 Arch. f. Psychiatrie, XXVI.

There are also to be noted a dyspeptic condition of the digestive tract which is often very marked; usually slight, sometimes severe albuminuria; a rapid, full, and bounding pulse which, in grave forms, becomes small and easily compressible. Under these unfavorable circumstances the general nutrition suffers and there is loss of flesh which becomes very considerable in a few days.