teristic signs of alcohol poisoning found in delirium tremens and polyneuritic psychosis, and in proportion as these are present or absent we may gauge the probability of alcohol being an essential and efficient cause of the mental disorder. We distinguish between delirium tremens, so common in males, as compared with females, and polyneuritic psychosis, in which the converse obtains, but it must be remembered that there is no hard and fast line between these two manifestations of nervous and mental disorder, the result usually of chronic alcoholism. I have seen cases of delirium tremens which, after the delirium had passed off, manifested well-marked symptoms of polyneuritic psychosis, and some cases of polyneuritic psychosis have symptoms like delirium tremens at the onset. This latter form of chronic alcohol poisoning may terminate permanent paralysis and contracture and marked alcoholic dementia, and the post-mortem findings in such cases reveal organic changes in the central and peripheral nervous system in measure proportional to the loss of function. Still, it is astonishing what improvement can occur in such cases if they are carefully nursed and properly treated to prevent permanent contracture and wasting.

in a

Chronic alcoholism may be manifested in the patient's conversation in various ways. There is often a tendency to wit and humour; the mental association is rather by rhyme and repetition of well-worn jokes, abusive epithets, and coarse vulgar stories than keen logical repartee. Again, boastful loquacity, untruthfulness, and the tendency to relate pseudo-reminiscences is a common symptom of chronic alcoholism. Especially characteristic is the mental confusion associated with the narration of pseudo-reminiscences.

A boastful loquacity frequently leads them into trouble, and of being suspected lunatics with delusions of grandeur. Their conversation may show a great deal of mental confusion and a tendency to wander incoherently from one subject to another without logical sequence, displaying a marked forgetfulness of what they had uttered a few minutes before. If their attention can be obtained it cannot be maintained, and there is a tendency to repeat themselves. They will talk unreservedly and unceremoniously in a familiar manner with either inferiors or superiors. This tendency to confabulate is a striking feature of chronic alcoholism in its manifold aspects. Personal illusions and affixing wrong names to persons are very common. Patients suffering with mental derangement from chronic alcoholism frequently are unable to correctly name the place where they are, or give the correct date or even the time of the year. Often a patient will tell you that she came to the asylum yesterday when she has been there months. Women suffering with polyneuritic psychosis are particularly liable to this loss of orientation in time and place. They may even forget where they live, although they remember where they went to school,

Loss of knowledge, or perhaps more correctly speaking, loss of recollection of events that happened since the patient had shown mental signs of the poisoning is common in women with polyneuritis pyschosis. One woman, a cook, with signs of syphilis, had been in Hanwell four months and told me that she came " last night." The curious part of her story is that she had been married twice; when her second husband visited her she believed him to be her first husband, who had been dead many years. Although this is strange, it is not altogether unexpected, for it is the rule that these patients, who are unable to revive in consciousness any recent events, yet are quite able to recollect all the events of their childhood and early life. A bookmaker who was suffering with chronic alcoholic dementia could not remember the name of the horse that won the last Derby, although he was told several times, yet he could repeat the winners for each year from West Australian up to a few years ago. Again, as showing the peculiar features of alcoholic poisoning, I may cite the following case: A woman at the climacteric period was admitted with alcoholic mania and suicidal tendencies. She was a good type physiognomically, although the flushed face with dilated venules on the nose indicated chronic alcoholism, to which she freely confessed. She said she wished to leave the asylum, there was nothing wrong with her, and the cause of her drinking was grief caused by the death of her husband, who fell in the dock and was drowned.

reason.

As many of these patients are not scholars I apply simple tests of memory, of attention, and of calculation involving simple judgment and I applied the following tests to this woman, who was able to give a coherent history of her life and knew the date she was admitted to the asylum, how long she had been here, and where she came from. I said to her : "You want to leave the asylum?" "Yes," she replied. "Then you must remember the name of the superintendent; it is Dr. Jones." She struck up a rhyme, "Oh Mr. Jones, oh Mr. Jones, he broke his bones by falling over cherry stones." I then asked her to remember the name, which she said she would have no difficulty in doing.

I then applied the second test. "You are given half-a-crown, and you go to a shop to buy half-a-pound of tea at 1s. 6d. per pound and a pound of sugar at 24d., how much change will you have?" She was quite unable to state the correct amount.

Again, they may be able to repeat the multiplication table correctly, but if you reverse the multiplication sum they will give wrong answers. Thus, they will give 7 by 5 correctly, but 5 by 7 they will make different. I now returned to my previous question, "Who is the Superintendent?" She had quite forgotten. When I said, "Who broke his bones?" she replied, "Why, Mr. Jones," and finished the rhyme, but was unable to reason from it that that was the name of the doctor who would be able to discharge her. Another test which I have

found useful for detecting slight mental impairment in cases that are recovering is that used by Marie in testing cases of aphasia.

Take three pieces of paper of unequal size. Tell them to carry out three separate and distinct operations for each piece. They will be able to carry out each order when given separately to them, but if before they commence any one the orders for the three are given together, they will forget and carry out the orders imperfectly. Thus, tell the patient to fold up the large piece and put it in his pocket, the middlesized piece to be folded and handed to you, and the small piece thrown on the floor. Whether it is the lack of power of attention or inability to recollect more than one order I know not, but the frequency with which failure occurs in alcoholic subjects shows mental impairment which is not discovered if any one order is given. With respect to this test I may remark that I recently had under my care in the hospital a case of polyneuritic psychosis complicated by syphilis, in which the patient on admission was apparently hopelessly demented, passing urine and fæces under him and showing marked mental confusion, tremors and paresis; yet withdrawal of the poison and energetic anti-syphilitic treatment for a fortnight led to a complete clearing up of the mental state, so that he performed this test correctly and also the calculation test. This made me think of the dictum of Dr. Savage, "With alcohol all things are possible." Another very severe case of paralytic polyneuritic psychosis is now under my care in the hospital, and is making a most remarkable recovery.

Certain Types of Alcoholic Insanity.

It is a well-known fact that a person, in getting drunk, may either become excited, boastful and grandiose in his ideas and conversation, as the French term it "vin gai," or melancholic, maudlin and sentimental -“vin triste;” so the cases of alcoholic insanity fall into two groups. The majority of the cases are either mania, frequently with depression or melancholia, but a few cases are exalted, boastful, loquacious, and have actual grandiose delusions so pronounced as to simulate general paralysis. In fact, these cases are often diagnosed as general paralysis, and no wonder, for in most cases of alcoholic poisoning, in the early stage, the pupils may be sluggish in their reaction to light, the facial expression altered, the tongue and lips tremulous, the speech is often slurred, and syllables may be left out, the handwriting tremulous; and not only may the spelling be incorrect, and the words cut up into separate syllables and letters and syllables left out, but marked mental confusion may show itself in the matter expressed. The knee-jerks are altered, sometimes exaggerated, sometimes diminished or lost. To these objective signs and symptoms must be added the symptoms of mental derangement. Loss of memory, loss of knowledge of time and place, hallucinations of sight and hearing, but most marked and perplexing in this class of case are delusions of wealth and grandeur,

instead of delusions of persecution, and it is the existence of these grandiose delusions which so often leads to an erroneous diagnosis of general paralysis. The dementia is, however, not progressive; the pupils, although at first sluggish in reaction, are usually not unequal, and the patient does not babble unsolicited of his wealth and grandeur as a general paralytic does, but only on questioning does he exhibit such delusions. The symptoms most alarming in their similarity to general paralysis may entirely disappear and the patient be discharged recovered; not infrequently, however, the opportunity of examining cases of this affection arises from death by intercurrent complications— e.g., pneumonia, dysentery or heart failure. The naked-eye and microscopic appearances are quite unlike those of general paralysis. Although the membranes may be opaque and thickened, there is but little wasting of the cortex; the floor of the fourth ventricle is not granular, or only slightly so in the lateral sacs. There is microscopically no disorganisation of Meynert's columns, and no evidence of lymphocytes or plasma-cells in the perivascular lymphatics of the cortex. The only definite microscopic change is some neuroglia cell proliferation in the subpial and septal structures of the cortex and replacement by it of the association fibres in the tangential and supraradial layers. Generally there is evidence of chromolytic changes of the pyramidal cells and active proliferation of young glia cells.

Dipsomaniacs are occasionally brought to the hospital and asylum. These are persons who have periodic cravings for alcohol, who in the interval lead a sober and respectable life. Suddenly, for no accountable reason save an unnatural and insane craving for drink, dipsomaniacs neglect their homes and their business, take little food, do not attend to their personal care and comfort, and, drinking continuously to satisfy their morbid craving, sink into the lowest depths of moral degradation, and for a time lead an unnatural and vagabond life. Some reason or other may bring such a patient to the hospital or infirmary, or they of their own free will return home, and in a short time recover and resume their normal life. A respectable photographer, with all the signs of delirium tremens, was admitted under my care at the hospital. He had a bottle of cyanide of potassium, with which he wanted to poison himself and wife. He had delusions that he was followed by a man named N- A hypnotic gave him a long sleep, and when he awoke all his delusions had disappeared, and he told me that he was not habitually intemperate, but that during the last few years he had had periods of craving for drink which he could not overcome. In the intervals he hardly touched anything, and lived perfectly happy with his wife and family. Curiously enough, he had had a similar attack two years ago, and had been brought to Charing Cross Hospital, when he had the same delusion about being followed by a man named N. He informed me that this man was dead, and that he had nursed him,

Epilepsy and Alcohol. It is well known that epileptics are particularly intolerant of alcohol, even in comparatively small quantities. The fits occur more frequently and are more severe, and it is certain that men who have even never had fits become epileptics in later life by the abuse of alcohol. I have observed, both in hospital and asylum practice, numbers of such cases; in some the epilepsy is the direct effect of the alcohol upon an inborn, potentially unstable, nervous system; in others it is the action of the poison upon a brain damaged by syphilis, arterio-sclerosis, or injury. One very interesting case of this was a soldier who was entirely free from any hereditary taint, and who rapidly rose to be a non-commissioned officer; he acquired in South Africa multiple cysticercus cellulosa. He had several fits, and was invalided home. About the worst thing possible was done for him he was put in charge of a canteen, acquired habits of drinking, eventually resulting in his developing alcoholic epileptic mania. He became a patient of Sir Victor Horsley's, who discovered the cause of the multiple tumours he had. He is now in Hanwell Asylum, and he is quite rational and does not suffer with any fits while he is unable to obtain alcohol.

It is not, however, in respect to the motor fits that alcohol is so dangerous to epileptics and potential epileptics; but in respect to the development of an impulsive automatism, causing them to commit indecent acts, crimes of violence, murderous assaults, and attempts at suicide, of which they may have no recollection. Some of the cases, however, of homicide and of attempted suicide remember perfectly well, and the question of responsibility for their action arises. (Vide report of Dr. Hubert Bond.)

Many of these epileptics are quite sane when they have been in the asylum a short time, and have to be discharged; frequently they are readmitted more than once owing to drink.

Other types showing intolerance to alcohol are imbeciles and degenerates. They are sometimes in prison, sometimes in the workhouses, sometimes in asylums, or in inebriate reformatories. A good example among many I could cite is Case E. J., who was sent to hard labour for three months and six months; subsequently he was sent to Hanwell, and he is there now, but he has been discharged and re-admitted six times. In the statistics such cases bulk largely in the recovery rate. It may well be asked, From what have such cases recovered? Not infrequently, history shows that such cases belong to a family of criminals, lunatics, and feeble-minded.

BRIEF ACCOUNT OF THE STRUCTURAL CHANGES IN ALCOHOLIC

POLYNEURITIC PSYCHOSIS.

The brains are generally of good weight, of good convolutional pattern, and do not as a rule show much evidence of thickening of the pia