Gentlemen!

I have already mentioned that a short-lived paranoid stage is often observed after a person in an alcoholic delirium wakes from the critical sleep. This phase seldom lasts longer than hours, or 2 days at most, and is well characterized by continued impairment of orientation and falsification of consciousness, and by belief in the lived reality of the dream experiences. However, in exceptional cases, even after an intervening stage of sleep, a state essentially the same as this paranoid stage can persist for weeks, months, and beyond—cases that can be described as ‘chronic alcoholic delirium’ [Ed] [1]. Chronic alcoholic delirium [W] develops either in the manner of an acute Delirium tremens [W] or as such a state which does not proceed with a distinct form, but more often as repeated abortive episodes limited to shorter periods of a few hours or less. An initial stage occurs, of variable duration, mixed in with traces to varying degrees of acute delirium, which never seem to be totally absent in cases of chronic alcoholic delirium. Furthermore, the chronic nature of these cases shows certain features that can probably be put down to an added component of alcoholic degeneration. These features include very severe loss of memory retention (but with a relatively intact store of past memory), disorientation—probably derived from this with respect to the immediate situation, and occurrence of confabulations, whether these are reported spontaneously, or are invented by the patients themselves to fill in noticeable lapses in memory for the recent past. It has already been emphasized that acute symptoms—hallucinations, and resulting restlessness and insomnia—are absent from this chronic delirium. It is still possible, even in chronic alcoholic delirium, for health to be restored if the patient’s general condition can be improved, and, with continued abstinence, other signs of cachexia and degeneration can be reduced. If this favourable outcome cannot be achieved, dementia ensues, with progressive dwindling of memory content and gradual loss of initiative.

Gentlemen! Our knowledge of chronic Delirium tremens [W] prepares us to learn about two further well-characterized types of illness, without my having to present you with examples. It will suffice to remind you of two earlier patients. You will remember the 41-year-old wife of a master tailor S., who I presented to you some time ago as an example of polyneuritic psychosis [W], and who had to be carried to bed because she was unable to walk, due to an atrophic paralysis of her legs of a polyneuritic nature. It was easy to gather psychological evidence from her because she showed herself to be completely level-headed and attentive, and examining her level of attentiveness by testing her domains of experience gave normal findings. More surprisingly, we soon encountered a combination of four familiar psychotic symptoms. The first was allopsychic disorientation: The patient had no idea where she was; she believed that she was a subject of an earlier fiefdom, and in the country as a temporary assistant; looking out of the window she recognized the towers of the neighbouring town of R.; she mistook me for the family doctor, the attendant nurse as his maid, and the medical assistant as the son of her sovereign. She regarded the current scenario as the session in a law court where she was to be heard; in the auditorium she believed that she recognized members of the court familiar to her from R., and several youthful acquaintances. She instantly recognized all other concrete objects and utensils. Her second symptom was a highly significant deficit in memory retention. The patient forgot in a moment what she had just said. A three-digit number, a foreign-sounding word which she should have retained after interposing a short question, was already forgotten, and a little while later, she had even forgotten that such a task had been set up. When she was shown an ophthalmoscope—an instrument unknown to her—a short time later, she looked at it with the same interest that she had been shown on the first occasion, and declared that she had never seen anything like it before. In like manner, neither did she know how she had come to the auditorium, and that she had been carried up two stories, nor did she know the time of day and whether she had had lunch or not. However, she thought that the latter was possible because she did not feel hungry. When I asked what she had done yesterday, she declared initially that she would have to think about this, but then recounted with all certainty and detail about an excursion with the family of the feudal estate to a local brewery and park in a neighbouring village. She also recounted various experiences from past days. She remembered precisely having put the children to bed the night before. She had been with this feudal lord for 16 years and had gone back temporarily because the lord was unhappy with his staff and she was unable to help her husband during the time of unemployment. Here we encountered the third conspicuous symptom: confabulation, or accretions of falsified memory. You will recall that I alluded to the connection of this symptom with thought deficits. However, the extent of this memory loss surprised us, for it extended far beyond the period of acute illness, going back years. There could be no doubt about the fact that such a deficit existed—as revealed most strikingly when I pointed out to the patient the contradiction between the paralysis of her legs and that she claimed to have gone for a walk for several hours yesterday. The origin of the paralysis was a total mystery to her.

Gentlemen! As you will remember, I have pointed out that such a loss of memory for the duration of her illness, that is, for the period when her retentiveness in memory had been lost, appeared easily understandable (p. 48), but also that a so-called retroactive amnesia (p. 40) was evident in this case. The patient still believed that, as before, she lived in R., whereas she had actually moved to Breslau with her husband several years ago. She remembered all too well her marriage and her maintaining friendly relations with her former community of R. Likewise, she gave entirely correct information from further back in her past life. She could easily prove that she still retained knowledge learned at school, insofar as could be expected of people of her age and circumstances. Admittedly, in mental arithmetic she failed completely, because, despite reliable multiplication of one number, she always forgot the other; however, working on paper she could solve arithmetic problems with several-digit numbers properly.