insisted upon, is found to be quite good." In the original description of the disease Huntington mentioned marked suicidal tendency as being very common,2 and this observation has been corroborated by most of the later writers.

Huntington's chorea is a chronic, slowly progressive, incurable affection. It cannot be said to be in itself fatal, death usually occurring at the end of many years from some intercurrent disease.

While the majority of cases correspond fairly closely to the above description, more or less marked variations from the most common type are frequently seen. The onset may occur at an early age, even in childhood or in infancy, or later than usual, in advanced senility; the symptoms may be mild, consisting of slight movements, limited in distribution, and unaccompanied by any mental disorder; or the mental deterioration may be particularly severe and set in long before the choreic movements develop.3

The anatomical changes found post mortem consist mainly of brain atrophy, shrinkage of cortical cells with dilatation of peri-cellular spaces, and occasionally internal hemorrhagic pachymeningitis.

1 W. G. Ryon. A Study of the Deterioration Accompanying Huntington's Chorea. N. Y. State Hosp. Bulletin, Feb., 1913. 2 George Huntington. On Chorea. The Med. and Surg. Reporter, Apr. 13, 1872.

3 C. B. Davenport.

Huntington's Chorea in Relation to Heredity and Eugenics. Proc. of the National Academy of Sciences, Vol. I, p. 283, May, 1915.

CHAPTER IX.

ACUTE ALCOHOLISM; PATHOLOGICAL DRUNKENNESS.

THE term drunkenness is here used to designate the nervous and mental symptoms by which acute alcoholic intoxication manifests itself.

The predisposition to the state of drunkenness, quite variable in different subjects, is a part of the general tendency of the individual toward nervous and mental disorders. "It may be truly said that alcohol is the touchstone of the equilibrium of the cerebral functions."1

1 Féré. La Famille névropathique. Paris. F. Alcan.— [This statement is correct, everything else being equal. But it must be borne in mind that there are other factors, besides mental instability, that have to do with an individual's susceptibility to alcohol. Age is one such factor, young persons being more susceptible than middle aged or old ones. But by far the most important factor is habit. We know well that it is not uncommon for morphine habitués, who have gradually acquired a tolerance for that drug, to take as much as twenty grains at a dose with no other than a mild euphoric effect, whereas one-fortieth of this dose produces profound sleep in an ordinary person, and one-tenth may readily prove fatal. We know also that the same kind of tolerance can be acquired for arsenic and for many other poisons, and, in fact, we often utilize this very principle in the artificial production of immunity against certain microbic toxines, such as those of diphtheria and tetanus. It is undoubtedly so also in the case of alcohol, for it is on the basis of such an acquired tolerance that chronic alcoholics universally boast of being able to "stand any amount" or at least of being "always able to navigate."]

I have now under observation an imbecile whom a single glass of wine suffices to make drunk.

Drunkenness is somewhat schematically divided into two stages: (1) excitement, and (2) paralysis. In reality paralysis is present from the beginning, but in the first stage it is limited to the highest psychic functions and is masked by the intensity of the automatic phenomena, so that it does not become evident until the second stage, when all the nervous and mental functions become involved in the paralysis.

First Stage: Excitement. Psychic inhibition, the first manifestation of the paralysis, is seen in the slow association of ideas, the distractibility, and the insufficiency of perception.1 The automatism is apparent from the disconnected conversation, which may show a true flight of ideas, the abnormal pressure of activity, the more or less marked morbid euphoria and irritability, the impulsive character of the reactions, and the extremely voluble speech. The moral sense and the regard for common conventionalities gradually disappear, and the patient may commit ridiculous, repugnant, offensive, or even criminal acts.

Second Stage: Paralysis. — Paralysis, confined in the preceding stage to the sphere of the higher psychic functions, now attacks the automatic functions. The movements are awkward and clumsy, the speech indistinct, the gait unsteady. Gradually the patient falls into a profound, sometimes comatose, sleep, the final stage of the attack, from which he awakes lucid but

1 Rüdin. Auffassung und Merkfähigkeit unter Alkoholwirkung. Kræpelins Psycholog. Arbeiten, Vol. IV, No. 3.

with a confused recollection of what has passed and with a pronounced sensation of mental and physical fatigue.

Such is, rapidly sketched, the aspect of common drunkenness. From the accentuation or obliteration of certain features result the diverse abnormal or pathological forms.

Comatose drunkenness. The phenomena of excitement are either absent or very transient. From the beginning the paralysis affects the entire brain. The patient sinks and remains inert and insensible for several hours. His face is congested. Gradually the comatose state is replaced by sleep, from which the patient awakes without any recollection whatever of the occurrences immediately preceding his intoxication. Sometimes the pulse becomes small, the heart weak, the breathing labored, and in some cases, which are fortunately rare, the patient dies in collapse.

Maniacal drunkenness. Here paralysis occupies a secondary position and excitement dominates the scene. The phenomena of agitation generally develop very rapidly. All of a sudden the drunkard, while still at the saloon-keeper's bar, is seized with an outbreak of furious madness without any apparent cause or provocation; he breaks objects and furniture, becomes noisy, and threatens and attacks those about him. The extreme clouding of the intellect shows that, in spite of appearances, "psychic activity takes but a very small part in the production of the outbreak,” and that "subjugated by this automatic development of psycho-motor activity it disappears entirely." 1. Almost

1 Garnier. La folie à Paris.

always numerous psycho-sensory disorders (hallucinations and illusions) are associated with the clouding of the intellect and the excitement.

The attack terminates in profound sleep. This, as in the preceding form, is followed by almost complete amnesia.

Convulsive drunkenness. The maniacal form of drunkenness resembles closely the delirious attacks of epilepsy. The relation between epilepsy and acute alcoholic intoxication appears still closer when we consider that drunkenness may clinically assume the aspect of an epileptic seizure. This is explained by the convulsive properties of alcohol, which have been demonstrated experimentally. Attacks precisely like those of essential epilepsy may supervene in the course of common drunkenness. In all cases they immediately follow the alcoholic excesses, differing in this respect from those epileptiform seizures which supervene in the course of chronic alcoholism.

Delusional drunkenness. This curious but rare form has been well studied by Garnier. The delusions are extremely variable: ideas of persecution, ambitious ideas, depressive ideas with suicidal tendencies, etc. Delusional drunkenness is encountered only in profoundly neuropathic individuals.

Pathological anatomy. The lesions of acute alcoholic intoxication have been studied chiefly in animals poisoned experimentally. Macroscopically there are conjestion and sub-pial hemorrhages. Microscopically are found, in addition to engorgement and distension of the blood-vessels, nerve cell changes consisting principally in swelling of the nuclei and peripheral