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.