CHAPTER VIII

THE PSYCHOSES DUE TO DRUGS AND OTHER EXOGENOUS TOXINS

Opium is a drug which has been in quite common use for many centuries. According to E. M. Holmes of London, it was known to Theophrastus nearly three hundred years before the Christian era and two different forms were described by Dioscorides in the neighborhood of 77 A.D. Nicander (185 to 135 B.C.) discussed at some length the effects of a "drink prepared from the tears which exude from poppy heads." Pliny in the first century A.D. recorded several cases of suicide by means of opium, which he spoke of as not being a rare occurrence. The drug is said to have been introduced into China by the Arabs in the thirteenth century. An edict prohibiting opium smoking was issued by the emperor Yung Cheng in 1729. It was not until 1909 that the British government agreed to completely prohibit the importation of morphine into China. The sale and use of narcotics has, however, been regulated in India for many years. Morphine, the first alkaloid ever discovered, was isolated and named by Sertürner, a German apothecary, in 1805. Over twenty derivatives of opium have been reported since that time. The real history of morphinomania, according to Erlenmeyer, began in 1864. As far as can be determined, opium was not grown in America until 1865. In 1906 it was estimated that over thirteen millions of people were addicted to opium smoking in China alone.

The literature of medicine contains numerous references to the mental disturbances due to opium and morphine. Krafft-Ebing[224] says of the habitual user that "Intelligence, it is true, is practically spared, but the highest mental functions—character, ethic feeling, self-control, mental energy, and force—always suffer.... In severe cases we find, in addition, weakness of memory, especially defect in the power of exact reproduction, difficulty of intellectual activity that may reach the degree of torpor, occasionally psychic depression reaching even marked dysthymia and taedium vitae, great emotionality, and, in general, profound deficiency of resistive power to affects; and besides, there may be episodically nervous restlessness, excitement, even attacks of fear due to vasomotor causes, and occasionally visual hallucinations." He also describes hallucinatory delirious conditions due to abstinence which strongly suggest alcoholism. In addition to clouded states of the same kind, Paton[225] speaks of the early occurrence, in chronic cases, of marked symptoms of hysteria. Apprehension and anxiety develop with mild suspicions and a moral deterioration very similar to that induced by alcohol. There may be considerable irritability and egotism, with a suggestion of flight of ideas and motor restlessness. Hallucinations and delusions are sometimes present, particularly if alcoholism is a complicating factor. Hyperesthesias, paresthesias and anesthesias are common. Barker[226] also speaks of a degeneration of character evidenced by ethical defects, lying, egotism and loss of memory. Under abstinence symptoms he includes restlessness, anxiety, despair, vomiting and delirium. White[227] regards the neuropathic diathesis as the most important cause of the morphine or opium habit. In habitual users he has noted hallucinated states with a paranoid coloring or a definite delirium. He has also observed delusions of persecution and poisoning, but emphasizes the importance of the gradual mental deterioration.

One of the most elaborate studies ever made of morphinism was that of Erlenmeyer,[228] whose work on this subject reached nearly five hundred pages in its third edition. The mental disturbances associated with intoxication he divides into two groups—transitory and permanent. The former includes anxious states, hallucinations of vision and stuporous attacks; the latter, the intellectual and emotional deteriorations already described. There is a definite character change strongly suggesting "moral insanity," an artificial "senium praecox" being induced. He also refers to distinct psychoses resulting from chronic morphinism, the most common one being of the paranoid variety. Abstinence symptoms of sudden development include collapse and delirium. Restless anxiety and insomnia may usher in a mild delirious condition. Of these he described two forms,—one, a quiet, partially clouded dream state and another, with excitement, elation and hallucinations. The first form is the more common. The second is usually of short duration but may last for several weeks or even months, often manifesting paranoid ideas.

Kraepelin[229] calls attention to the important fact that morphine stimulates mental activities as well as inhibiting psychomotor processes, and is not therefore a logical drug for the production of sleep. The habitué feels himself capable of much greater exertions but is handicapped by an inhibition of will power. This psychological mechanism determines the difference between the intoxication of morphine and that of alcohol. Nissl found the cortical cells of dogs poisoned with morphine decreased in size but not destroyed. The stainable substance was rarefied and weakly stained, the achromatic substance, on the other hand, being unusually prominent. In chronic morphinism Kraepelin found memory uncertain, mental capacity diminished and fatigability increased. There are alternating periods of comparatively good health and dull somnolence with exhaustion or nervous restlessness. The mood is variable,—depressed, discouraged, hypochondriacal, irritable, or even confident and overbearing. Anxious states occasionally occur at night and suicidal attempts may be made. Character changes are also described by Kraepelin. The patients become complaining, oversensitive to pain and to opposition, are indolent, irresolute, irresponsible and neglect their work. Their interest is more and more confined to the drug. Their untruthfulness and deceitfulness are well known. Sleep is much disturbed, often by visual hallucinations. Phantastic delusional ideas are also manifested. Paresthesias and hyperesthesias are common. The reflexes are active and usually increased. The gait is unsteady or even ataxic. Speech disturbances, paralysis of the muscles of the eye, diplopia and loss of accommodation have been noted. A typical Korsakow's complex was observed by Heymann. Appetite is lost, bodily weakness and loss of weight appear and sugar is often present in the urine. Perspiration, dizzy spells, confusion and stupor may be caused by circulatory disturbances. Sexual power is diminished, and menstrual disturbances are frequent. These symptoms may appear early or may not develop for years, depending on the individual case. Kraepelin also describes forms similar to dipsomania in alcoholics. He attributes these to epileptic or hysterical constitutions. Many of his cases were decidedly psychopathic with tendencies to abuse the use of alcohol, tobacco and coffee. Of thirty-eight patients observed by him, nineteen used only one drug, ten of them were addicted to two, eight others to three, and one patient to as many as five. Under abstinence symptoms he includes exhaustion, restlessness, yawning, sneezing, anxiety, chilliness, oppression, sense deceptions and pains in various parts of the body. The patient is sleepless and sometimes goes into an excitement with suicidal inclinations. In some cases a condition develops which markedly resembles delirium tremens. In others, hallucinatory symptoms are more marked. These manifestations may last for several days or for a few weeks. Hysterical dream states with hallucinations and convulsive seizures may also occur.

Cocaine was first isolated by Gardeka in 1855, but was given the name it now bears by Niemann. It did not come into extensive use until many years later and was not employed generally in ophthalmological practice until about 1884. Freud in 1885 called attention to the fact that small doses of cocaine produced a stimulation of the mental activities with euphoria and an increased capacity for both mental and physical work. Mannheim,[230] who reviewed ninety-nine cases of cocaine poisoning in 1891, found that the first symptoms were drowsiness and deep sleep, occasionally followed by coma and collapse. He observed that some patients became restless and excited, dizzy, laughing and crying alternately, while others were very talkative and uneasy, walking up and down with a drunken gait. Usually he found a complete amnesia afterwards.

The first study of psychoses due to cocaine was made by Erlenmeyer[231] in 1886. As he afterwards modestly observed, "This first report on cocomania, which was founded on thirteen cases, completely exhausted the subject, and nothing essential has been added to the symptomatology then published." He found that it was almost always combined with the morphine habit. This was probably due to the fact that cocaine, at one time, was used extensively in the treatment of morphinism. Although the assimilation of food is not affected and gastritis was not a symptom, Erlenmeyer usually found a great decrease in bodily weight, as much as twenty to thirty per cent in some cases within a few weeks. Sleep is much disturbed and insomnia the rule. The most common form of mental disturbance he found to consist of attacks of violent excitement accompanied by delusions of persecution. Dangerous, impulsive assaults may occur. Very often, however, there were transitory confusional states with hallucinations of hearing and vision, succeeded by a mental deterioration and loss of memory. Visual hallucinations usually appear early. A common and peculiar symptom is the appearance of dark spots and points on a white background, attributed by Erlenmeyer to multiple scotomata. Auditory hallucinations he also found to be frequent. Sensory deceptions give rise to peculiar ideas such as the presence of the "cocaine bug" which the patient often tries to catch. Volubility is another characteristic feature of the disease which he refers to. As abstinence symptoms he describes forms of depression, with weakness of will power. Barker refers to psychoses of an acute hallucinatory confusional type as a result of cocainism.

Krafft-Ebing speaks of episodic toxic deliria with visual and auditory hallucinations resembling those of alcohol and accompanied by delusions of persecution or jealousy with visions of multitudes of small animals, etc. He has not observed delirious conditions due to abstinence.

In acute cocainism Kraepelin[232] finds an increased pulse rate, a lowering of blood pressure and the appearance of an excitement of the intoxication type with an agreeable sensation of warmth and well-being. There is an initial motor excitement followed eventually by weakness. This is a somewhat similar reaction to that caused by alcohol, but it is more marked. Small doses cause the habitué to feel elated, talkative and inclined to prolific writings. He feels a greatly increased efficiency but does not show a corresponding productivity. Larger doses cause delirious excitement with a tendency to sudden collapse. After a prolonged use of the drug a condition of nervous excitement ensues, with an increasing susceptibility to intoxication, a mild flight of ideas, a diminished capacity for mental exertion, loss of will power and failure of memory. The patient is busy with entirely useless activities, quite voluble, and writes incessantly. He becomes unreliable, forgetful, disorderly and careless in his conduct. The mood alternates between one of well-being, irritability, suspicious anxiety and emotional dulness. Kraepelin speaks of the great loss of weight, increased reflexes, dilated pupils, rapid pulse, etc. Insomnia is a common symptom. The characteristic psychosis of cocaine, however, in his opinion is a paranoid condition somewhat resembling the alcoholic forms. The onset is usually sudden, with irritability, suspicion and anxious restlessness, together with the sudden development of hallucinations of various kinds. Auditory hallucinations are particularly numerous and are very active. The patient's surroundings appear strange and unreal. He sees all kinds of pictures of the most realistic type. Tactile hallucinations are very common. The patient often shoots at his imaginary persecutors or attempts suicide to escape them. A typical symptom is the appearance of delusions of jealousy. With all of this the patient is usually well oriented. Only occasionally is there a clouding of consciousness and confusion. Insight is, however, always lacking. Even with a clear sensorium the delusional ideas are firmly retained. The mood is excited, irritable, sometimes angry and exasperated, but most frequently depressed and suspicious. The conduct is characterized by restlessness and uncertainty. There is usually a marked volubility suggesting a conscious delirium at times. The whole development of these conditions is rapid, often within a few weeks. They disappear as quickly in many instances.

Chronic cocainism is very similar to the alcoholic conditions. From a symptomatic point of view, however, the paranoid cocaine psychoses occupy relatively an intermediate position between alcoholic delirium and the paranoid states.

In experiments on dogs Nissl found a stainability of the achromatic substance in the neurones, a beginning shrinkage of the cell nuclei and a slight increase of leucocytes in the pia and vessels.

Chloral-hydrate, which has been employed medicinally since 1869, is much less frequently a cause of mental disturbance than morphine or cocaine. Krafft-Ebing describes its use combined usually with other drugs as causing moroseness, depression and mental dulness. He speaks, too, of a delirium due to sudden withdrawal. This condition, he says, may also be caused by paraldehyde. The craving for chloral, on the part of those who have acquired the habit, is much less intense than that for morphine or cocaine. Other drugs are very readily substituted for that reason. A prolonged use leads to digestive disturbances, constipation alternating with diarrhea, jaundice, flushing of the face, congestion of the conjunctiva, fulness of the head, palpitations, weak pulse, dyspnea and general malnutrition with erythematous, urticareous or pustular skin eruptions, etc. Hyperesthesias, anesthesias, paresthesias, pains in the limbs, sensations of heat and cold, tremors, occasional loss of muscular power and sometimes ataxia appear. The reflexes are usually decreased. Epileptiform convulsions have been observed although they are infrequent. The mental disturbances of chloral have been studied by Wilson.[233] He describes the habitué as "dull, apathetic, somnolent, disposed to neglect his ordinary duties and affairs. He passes much of his time in a state of dreamy lethargy or in deep and prolonged sleep, from which he awakes unrefreshed and in pain." Headache is an almost constant symptom. It is associated with "confusion of thought, inability to converse intelligently or to articulate distinctly, and other evidences of cerebral congestion." Vertigo is also common. The mental state is characterized by dulness, apathy and confusion, alternating with periods of irritability and restlessness. The depression is not so marked as in morphinism. Inability to concentrate the mind, loss of memory, and intellectual enfeeblement are terminal conditions. Occasionally in the worst cases hallucinations, delusions, clouding and states of excitement are observed. Abstinence symptoms are headache, insomnia, neuralgia, pains in the limbs, nervousness, restlessness and formication. A delirium similar to that of alcoholism has been referred to by various writers.

Casamajor[234] has described two types of mental disturbance due to the use of bromides,—a condition of apathy with dulness and an active delirium. The first is characterized by apathy, dulness, somnolence, weakness and failing memory, and is often observed in epileptics who have been subjected to protracted periods of bromide treatment. He has also reported toxic deliria showing marked hallucinations with psychomotor unrest, fabrications and paraphasia. This may be associated with unequal, sluggish pupils, increased or unequal patellar reflexes, tremors, ankle clonus and an unsteady gait—a general condition suggesting paresis. Hoch[235] also reported cases showing hallucinations, clouding, disorientation, amnesia, fabrications and aphasic disturbances, together with physical signs simulating general paresis. O'Malley and Franz[236] described somewhat similar symptoms in a case showing dilated sluggish pupils, exaggerated knee-jerks, ankle clonus, tremors and unsteady gait, etc. The mental disturbance was characterized by a confused dreamlike state, with hallucinations, memory defect, a disturbance of attention, and a marked tendency to fabrication. The fabrication in their opinion suggested a delirious origin rather than the Korsakow complex.

The first references to the psychoses caused by lead intoxication were apparently those of Dehäne in 1771. Tanquerel des Planches published his "Encephalopathia Saturnina" in 1836. He recognized three forms of this condition,—the delirious, the comatose and the convulsive. Edsall[237] describes as encephalopathies all of the cerebral symptoms due to chronic lead poisoning. In addition to transitory hemiplegias, aphasia and choreiform movements, he refers to the occurrence of hysterical manifestations, such as hemianesthesias associated with outbursts of excitement. Coma and clouded states often occur. These may be accompanied by convulsions. In the delirious form there may be a marked excitement with psychomotor activity. Hallucinations are common, particularly in alcoholic cases. Delusions of persecution are not infrequent. There is usually a rise of temperature throughout the attack. The delirium may last from a few days to several weeks. Symptom complexes strongly suggesting general paresis have been reported. Krafft-Ebing speaks of psychoses characterized by mental depression, feelings of oppression, irritability, mild delusions of persecution and terrifying hallucinations. Epileptiform attacks, paralyses and tremors are also mentioned. He refers to deliria which may arise spontaneously or follow an initial stupor, and speaks of the chronic lead psychoses as toxic hallucinatory confusional conditions. Six cases of this nature were reported by Bartens in 1887. Oppenheim has occasionally found hysterical symptoms associated with chronic lead poisoning. Rayner[238] found mental disturbances preceded by such premonitory symptoms as headache, restlessness, disturbed sleep, terrifying dreams, tinnitus aurium, flashes of light, difficulty of thought, and depression. This terminated in a few days in a delirium characterized by anxiety and visual hallucinations. Other cases showed a more marked depression and stupor, sometimes alternating with delirium and violent excitement, accompanied by hallucinations and speech defects. Amaurosis and convulsions are spoken of frequently as common symptoms. Conditions similar to general paresis have been noted by various observers.

There have been very few contributions to medical literature on the subject of psychoses caused by arsenic. In discussing forms of poisoning due to that drug Edsall expressed the opinion that "marked psychic symptoms are unusual." Casamajor makes the statement that "in very severe cases memory disturbances have been noted, and in some the typical Korsakow polyneuritic psychosis." According to Oppenheim a rise of temperature associated with a delirium may be observed at the onset of arsenical poisoning and may also occur later in the disease. Psychoses due to arsenic were not referred to by Krafft-Ebing, Arndt, Schüle, Ziehen or Kraepelin.

Edsall[239] mentions as the symptoms of chronic mercurial poisoning, headache, restlessness, mental depression and weakness. Most striking features are tremors and a peculiar emotional disturbance referred to as "erythism." Tremors of the lips and facial muscles are common and speech disturbance and choreiform movements have been noted. Symptoms suggesting neurasthenia and hysteria have also been reported. Naunyn has described excitements due to mercury characterized by anxiety and fears with hallucinations and sleeplessness. He also speaks of manic attacks, depressions and mental deterioration as associated conditions.

Argyria or chronic silver poisoning is said to be accompanied often by a marked sensitiveness and occasional episodes of actual depression due to the discoloration and pigmentation of the face.

Psychoses due to various gases are occasionally encountered. Illuminating gas is a rather common means of suicide, as is shown by the newspapers. It has been found that the cause of death in these cases is carbon monoxide, which is also often reported as responsible for the asphyxiation of workmen in garages and other places where gasoline motors are used. This occasionally results from the improper ventilation of laundries, engine rooms, gas plants, iron foundries, etc. These conditions have been very fully studied by O'Malley.[240] The mental disorders due to carbon monoxide are described as being characterized by a sudden attack of confusion and clouding associated with a period of complete amnesia. There may be disturbances of attention and Korsakow's psychosis is sometimes strongly suggested, with memory impairment and tendencies towards fabrication. This condition may be transitory or last for many months. On recovery the patient usually has no recollection of any events taking place after the time of the poisoning. Immediately following the initial unconsciousness there may be excited periods or delirious states with aphasic disturbances. In chronic cases delusions of persecution are often observed. The psychosis frequently does not develop until several weeks or months after the actual poisoning. Several observers have referred to a mask-like expression of the face, with emotional indifference, apathy and outbursts of laughter. The mood has been described as characterized by emotional instability. O'Malley calls attention to the important fact that the mental disturbance may have been the cause of suicidal attempts rather than a result of the gas poisoning. Confused delirious states due to carbon monoxide poisoning, also conditions resembling Korsakow's disease, have been described by Kraepelin. Several cases somewhat similar to that described by O'Malley have been observed at the Boston State Hospital.

An analysis of the statistics of American institutions shows that psychoses due to drugs and other exogenous poisons are quite rare in this country. They represented only .39 per cent of the admissions to the New York state hospitals during a period of eight years. The number admitted to Massachusetts hospitals is still less. In a total of 70,987 first admissions to forty-eight hospitals in sixteen different states there were only 324 cases due to exogenous poisons. This constituted .65 per cent of the total number admitted. It is interesting to note that during a period of eight years, when 49,640 cases were admitted to the New York state hospitals, 154 cases of psychosis due to opium or morphine were reported, five due to metallic poisons, eighteen caused by gases, and nine of types unspecified. No case of uncomplicated cocainism was reported during that period of time.

The 314 drug habitués in the state hospitals of the entire country as shown by the census of January 1, 1920, and reported by the National Committee for Mental Hygiene, represented .15 per cent of the mental cases under treatment in those institutions on the same date. The 808 drug addicts shown by the same census in all of the institutions of the United States, both public and private, represented .34 per cent of the mental cases reported by them. The fact that the private hospitals showed 4.5 per cent of drug cases in the same census is significant. It indicates that these cases are largely cared for in institutions of that type, and furthermore, that their number is very small.

The result of the investigations made in 1919 by a committee appointed by the Secretary of the United States Treasury is of great interest in view of the number of drug psychoses treated in our state hospitals. The committee's report[241] shows an estimated annual per capita use of opium in Italy of 1.25 grains; Germany, two grains; France, three; Holland, 3.5; and the United States, thirty-three grains. More opium is consumed here than in any other country in the world. The committee was of the opinion that ninety per cent of it was used for other than medicinal purposes. The estimated number of habitués in New York City at that time as reported by the City Commissioner of Health was 103,000. The questionnaire sent out by the committee to physicians registered under the Harrison Act showed that the number of cases under treatment for morphinism in various parts of the country was as follows:—California, 3,338; Connecticut, 11,740; Illinois, 8,218; Indiana, 8,438; Massachusetts, 14,770; New Jersey, 5,900; New York, 37,095; Pennsylvania, 10,202, etc. The estimated number of drug users in the United States was given at one million, and the amount of money expended by them annually was said to approximate sixty-one million dollars. In view of these statements the number of psychoses reported in the hospitals is astonishing.