Korsakow's psychosis was first described in 1887. This is characterized by a loss of memory, and falsification, with a marked tendency to disorientation, and is often due to chronic alcoholism. It is practically always accompanied by polyneuritic symptoms. According to Bonhöffer, it usually follows delirium tremens. This occurred in one-fourth of Kraepelin's cases. Occasionally it begins suddenly, but as a rule gradually, during the course of a chronic alcoholism. The patients frequently complain of dizziness, headaches and fainting spells. In the foreground of this affection is the impairment of memory. This is one of the characteristic features. The events of a few hours ago are completely forgotten. Disorientation appears next. This affects time more than anything else. The power of apprehension or perception is very markedly impaired (one-sixth of the normal in Kraepelin's cases) and the reaction time is greatly increased. He also found memory reduced to one-third or one-fourth of the normal on actual tests (repetition of words and syllables). Falsification of past events is also demonstrable. This often leads to elaborate delusion formations. The mood is usually anxious at first, later indifferent, dull, suspicious, irritable, in some eases cheerful and even humorous. The methods of life are completely changed. The patients neglect themselves, lie in bed, etc. The physical signs are those of neuritis. Muscular pains in the limbs appear, with evidences of loss of power. Paraplegias and weakness of the grip are found. Romberg's sign is frequently present. Anesthesias, hyperesthesias or paresthesias are noted. The reflexes are usually decreased, rarely increased. Ataxia and other difficulties of gait are common. The pulse is usually slower as a result of involvement of the vagus. Speech difficulty, writing defects, facial paralyses, weakness of the eye muscles, with inequality and inactivity of the pupils, are to be expected. There are usually tremors of the fingers. Epileptiform convulsions are not infrequent. Aphasia, agraphia, apraxia, monoplegia, hemiplegic, etc., are observed in many cases. Physical disturbances of various kinds due to chronic alcoholism are also present.
At autopsy acute and grave alterations are found in the cells of the second and third layers of the cortex. A granular degeneration (Körnig Zellerkrankung) of the cells is also referred to by Nissl. There is some fibre loss in the central convolutions and the internal capsule, as well as in the columns of Goll. Hemorrhages and thromboses are to be found. Alzheimer found encephalitic foci with proliferation of the cells of the vessel walls sending out fibroblasts in the neighborhood, and a destruction of the nerve fibres. These foci are found in the central gray matter of the third ventricle, roof of the aqueduct, etc. There is a formation of new vessels and an outwandering of cells often accompanied by numerous hemorrhages into the gray matter around the aqueduct of Sylvius. Wernieke has described this process as an "acute hemorrhagic polioencephalitis superior" and finds it very commonly associated with Korsakow's psychosis. It occurs, however, in other chronic alcoholic conditions. The peripheral nerves also show a polyneuritis. Bonhöffer found Korsakow's psychosis in three per cent of his delirious cases. Thirty-three per cent of Kraepelin's cases were women and only 24.5 per cent were under forty years of age. Chotzen found Korsakow's psychosis in three per cent of his male and in twenty-one per cent of his female alcoholics.
The acute alcoholic hallucinoses as described by Kraepelin are characterized by well defined delusions of persecution and above all by hallucinations of hearing, with a clear sensorium. In eighty per cent of the cases the symptoms appear suddenly. Sometimes there is first an abortive delirious attack. Usually a multiplicity of hallucinations of hearing develop early. The patient hears threats and abusive language, always directed against himself. Visual hallucinations also occur, particularly at night. The other sensory fields are often involved. At the same time well marked delusions manifest themselves. These suggest every possible variety of persecution. Ideas of grandeur are sometimes observed. All of these symptoms are worse at night as a rule. Consciousness is usually fairly clear, and there is no disorientation. There is often a mixture of anxiety and humor. Some cases, however, are irritable and suspicious. Occasionally suicidal tendencies appear. Conduct is usually not greatly disturbed and the patient continues with his regular occupation. There is considerable insomnia and a tendency to run around a great deal and act foolishly at times. Physically, evidences of chronic alcoholism are always to be found. The customary duration of these acute conditions is from three to eight weeks, although they sometimes last for months. In a quarter of Kraepelin's cases the termination was in deterioration. There is a strong tendency to recurrence. The unrecovered cases are suspicious, surly, quarrelsome and have hallucinations of hearing. This condition may last for years. There are always occasional persecutory ideas. One-fifth of Kraepelin's cases became chronic. Bonhöffer described a paranoid type of long duration. The hallucinoses appear usually earlier in life than Korsakow's psychosis but later than delirium tremens. In Kraepelin's experience delirium tremens is three times as common as are hallucinoses. He looks upon these two conditions, however, as different clinical manifestations of "one and the same" disease process.
Alcoholic paralysis, so called, is a mixture of chronic alcoholic symptoms with those of general paresis. There is a mental deterioration with ideas of grandeur, emotional dulness, hallucinations, delusions of jealousy, speech defect, tremors and polyneuritis. Epileptiform attacks are frequent. Most of these forms according to Kraepelin belong to Korsakow's psychosis or polioencephalitis hemorrhagica superior. Alcoholic conditions may also be complicated by syphilis or arteriosclerosis.
Since the alcoholic psychoses have been generally recognized as such, there has been comparatively little difference of opinion as to their differentiation. The classification of the American Psychiatric Association is as follows:—
"The diagnosis of alcoholic psychosis should be restricted to those mental disorders arising, with few exceptions, in connection with chronic drinking and presenting fairly well defined symptom-pictures. One must guard against making the alcoholic group too inclusive. Overindulgence in alcohol is often found to be merely a symptom of another psychosis, or at any rate may be incidental to another psychosis, such as general paralysis, manic-depressive insanity, dementia praecox, epilepsy, etc. The cases to be regarded as alcoholic psychoses which do not result from chronic drinking are the episodic attacks in some psychopathic personalities, the dipsomanias (the true periodic drinkers) and pathological intoxication, any of which may develop as the result of a single imbibition or a relatively short spree.
"The following alcoholic reactions usually present symptoms distinctive enough to allow of clinical differentiation:
"(a) Pathological intoxication: An unusual or abnormal immediate reaction to taking a large or small amount of alcohol. Essentially an acute mental disturbance of short duration characterized usually by an excitement or furor with confusion and hallucinations, followed by amnesia.
"(b) Delirium tremens: An hallucinatory delirium with marked general tremor and toxic symptoms.
"(c) Korsakow's psychosis: This occurs with or without polyneuritis. The delirious type is not readily differentiated in the early stages from severe delirium tremens but is more protracted. The non-delirious type presents a characteristic retention defect with disorientation, fabrication, suggestibility and tendency to misidentify persons. Hallucinations are frequent after the acute phase.
"(d) Acute hallucinosis: This is chiefly an auditory hallucinosis of rapid development with clearness of the sensorium, marked fears, and a more or less systematized persecutory trend.
"(e) Chronic hallucinosis: This is an infrequent type which may be regarded as the persistence of the symptoms of the acute hallucinosis without change in the character of the symptoms except perhaps a gradual lessening of the emotional reaction accompanying the hallucinations.
"(f) Acute paranoid type: Suspicions, misinterpretations, and persecutory ideas, often a jealous trend, hallucinations usually subordinate; clearing up on withdrawal of alcohol.
"(g) Chronic paranoid type: Persistence of symptoms of the acute paranoid type with fixed delusions of persecution or jealousy usually not influenced by withdrawal of alcohol; difficult to differentiate from non-alcoholic paranoid states or dementia praecox.
"(h) Alcoholic deterioration: A slowly developing ethical, volitional and emotional change in the habitual drinker; apparently relatively few cases are committed, as the mental symptoms are not usually looked upon as sufficient to justify the diagnosis of a definite psychosis. The chief symptoms are ill humor and irascibility or a jovial, careless, flippant, facetious mood; abusiveness to family, unreliability and tendency to prevarication; in some cases definite suspicions and jealousy; there is a general lessening of efficiency and capacity for physical and mental work; memory not seriously impaired. To be excluded are residual defects due to Korsakow's psychosis, or mental deterioration due to arteriosclerosis or to traumatic lesions.
"(i) Other types, acute or chronic (to be specified)."
Shadwell[222] states that in twenty-six Italian asylums 18.6 per cent of their cases were directly or indirectly the result of alcoholism. Twenty-one and one-tenth per cent of the males and 4.37 per cent of the females admitted to the institutions of Switzerland from 1901 to 1904 were alcoholics. Twenty-one and thirty-seven hundredths per cent of the admissions to the hospitals in Denmark between 1899 and 1903 were suffering from alcoholic psychoses. He gives the admission rate in Austria as fourteen per cent and in France, 12.5 per cent. Clouston some years ago estimated the admission rate in Great Britain and Ireland to be about twenty per cent.
Pollock[223] has made a most interesting study of 1,739 cases of alcoholic psychoses, the total number admitted to the New York state hospitals between October 1, 1909, and September 30, 1912. Seventy-six and five-tenths per cent of these were men, and 23.5 per cent, women. The different conditions represented were as follows: Pathological intoxication, .7 per cent; alcoholic deterioration, 7.7 per cent; delirium tremens, 4.7 per cent; Korsakow's psychosis, 18.8 per cent; acute hallucinosis, 36.7 per cent; chronic hallucinosis, 2.2 per cent; paranoid states, 13.7 per cent; and all other forms, 15.5 per cent. Among the males, acute hallucinosis predominated, while Korsakow's psychosis constituted the largest percentage in the female patients. Of the ascertained cases, .4 per cent showed a defective make-up, 10.3 per cent were inferior and 89.3 per cent were reported as normal. In seventy-four per cent of the cases there was no history of insane heredity. The father of the patient was insane in 3.7 per cent of the series and the mother in four per cent; 25.8 per cent in all had a history of insane heredity. Thirty and five-tenths per cent of the male and thirty-seven per cent of the female patients had alcoholic fathers and three per cent of the men and 8.8 per cent of the women had alcoholic mothers. Pollock found the percentage of intemperate fathers twice as high in the alcoholic psychoses as in the patients suffering from other conditions. In 94.1 per cent of the cases there was no family history of nervous diseases. Eighty-one and one-tenth per cent of the men and 93.4 per cent of the women came from cities. Of the male patients 26.8 per cent were unskilled laborers; 16.1 per cent of the women were seamstresses, and 11.7 per cent, the wives of laborers. The alcoholic cases constituted fifteen per cent of the male, five per cent of the female, and ten per cent of the total first rate admissions during the three years in question. The rate of alcoholic psychoses was over twice in as great in the foreign born population as in the native.
Three thousand four hundred and sixty-two cases diagnosed as alcoholic psychoses were admitted to the New York state hospitals during a period of eight years (1912 to 1919 inclusive). Of these, pathological intoxication constituted 2.91 per cent, delirium tremens, 5.97 per cent, Korsakow's psychosis, 20.94 per cent, acute hallucinosis, 37.31 per cent, chronic hallucinosis, 3.66 per cent, acute paranoid states, 5.01 per cent, chronic paranoid states, 3.78 per cent, and alcoholic deterioration, 8.34 per cent. The remainder represented miscellaneous types variously described. These figures, of course, relate largely to a time when there were no restrictions on the sale of alcoholic beverages. During 1918 and 1919 the admission rate for alcoholic psychoses in New York was only 4.58 per cent. In Massachusetts in 1919 it was 7.47 per cent, and in twenty-one other hospitals in various states it was 5.04 per cent. A study of 34,935 first admissions to forty-eight hospitals in sixteen different states during 1917, 1918 and 1919 showed the alcoholic psychoses to represent 5.07 per cent of the total number. With the advent of prohibition the alcoholic psychoses as far as this country is concerned have become a matter of little more than historical interest. The admission rate in the New York state hospitals for 1920 was only 1.9 per cent.
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.
CHAPTER IX
THE PSYCHOSES WITH PELLAGRA
The origin of pellagra is shrouded in mystery. Although first described by Casal, the name now attached to the disease was suggested by Frappoli in 1771. He referred to it as of ancient origin at that time and probably identical with the "pellarella" reported in Milan in 1578. Niles[242] is of the opinion that the peculiar malady existing among the American Indians and mentioned by Baruino in 1600 was almost certainly pellagra. It is interesting to note that he attributed it to the use of corn. The disease was observed in Spain by Gaspar Casal in 1735 and appeared in Italy about twenty-five years later. Of the 4,404 admissions to the St. Clement's Hospital at Venice between 1873 and 1880 over thirty per cent showed symptoms of pellagra. In 1912, according to Niles, the number of cases in Italy was estimated at approximately one hundred thousand. The disease was apparently first reported in France in 1818. It has been common in Egypt since 1892 at least and is said to have occurred there as early as 1847. Cases were reported in this country by John P. Gray at the Utica State Hospital and by Tyler at the McLean Hospital, in Somerville, Massachusetts, in 1863. It is now thought to have been very common in the Andersonville and Libby prisons during the civil war, although not diagnosed as such at the time.
Few cases were reported in this country prior to 1907, when it was found to be present at the Columbia, South Carolina, State Hospital by Babcock. Pellagra constituted seven per cent of the admissions to that institution in 1908, fifteen per cent in 1909, twenty in 1910, over twenty-seven in 1911 and twenty-six per cent in 1915. Sixty-one per cent of the deaths in the hospital during the latter year were due to that disease. The health officer of the state reported four hundred cases in South Carolina in 1909 and six thousand in 1914. Babcock is now of the opinion that pellagra undoubtedly existed for twenty years or more at Columbia before its significance was known. In 1910 the disease was found to be present in thirty different states and represented about three thousand cases.[243] Of these the largest numbers were in Virginia, North Carolina, South Carolina, Georgia, Alabama, Mississippi, Louisiana, Texas, and Illinois. The importance of this question had already been recognized and a national conference was held on the subject at Columbia in 1909. During the same year the governor of Illinois appointed a commission to make a thorough study of pellagra in that state. The disease has been made the subject of elaborate investigation and study by the United States Public Health Service and several publications have been issued by that department.[244]
Notwithstanding the extended discussion and scientific research of the last few years, the question as to the definite etiology of pellagra has not as yet been positively settled. The maize or Indian corn theory was first advocated by Mazari in 1810. He believed the symptoms to be due to a deficiency in gluten. Sette in 1826 attributed the disease to a fungus (scimelpige) growing on corn and producing a poison from the oil in the grain. The smut of corn, "Ustilago Maydis," was suggested as a possible factor by Pari in 1860. In 1872 Lombroso formulated his toxic theory: "In pellagra we are dealing with an intoxication produced by poisons developed in spoiled corn through the action of certain microorganisms, in themselves harmless to man." He also announced the discovery of "pellagrosein," a toxic substance extracted from spoiled corn. In 1902 Ceni advanced the theory that the disease was caused by the action of certain moulds such as the aspergillus fumigatus and flavescens. The Illinois Pellagra Commission in 1911 came to the conclusion after an elaborate investigation of the subject that the primary etiological factor involved was a living microorganism of unknown nature, that the probable source of infection was through the intestinal tract and that a deficient amount of animal protein in the diet probably acted as a predisposing cause. Funk in 1914 suggested a vitamin deficiency in the diet brought about by the consumption of overmilled corn. Voegtlin[245] in the same year expressed the opinion that the disease was essentially a chronic intoxication,—"While the agents at work in this intoxication are as yet unknown, I am inclined to believe that toxic substances exist in certain vegetable foods, not necessarily spoiled, which, if consumed by man over a long period of time, may produce an injurious effect on certain organs of the body.... It is probably more than a mere coincidence that the population of that part of the world in which pellagra is endemic lives on a mainly vegetable diet."
In 1916 a study was made by Koch and Voegtlin[246] of the chemical changes found in the nervous system in pellagra which was very significant in its results. They found an increase in water with a decrease in proteins and lipoids, the latter reaction being attributed to a degeneration in the white matter. There was also a relative increase in the cholesterol content, looked upon as a compensatory protective function tending to replace the loss in lipoids. The most marked chemical alterations were found in the cord. On feeding monkeys and rats with an exclusive vegetable diet, changes in the chemical reaction of the brain and cord of almost exactly the same type were brought about experimentally.
Goldberger[247] in 1916 made an interesting report of a series of investigations carried on by the United States Public Health Service at Jackson, Mississippi. A large number of cases of pellagra were treated by largely supplementing the dietary with fresh meats, milk and leguminous vegetables. The carbohydrate content was reduced at the same time but corn was not entirely discontinued. Of 209 cases studied, 172 remained under continuous observation with a recurrence of symptoms in only one case. In a similar experiment made at the Georgia State Sanitarium seventy-two patients, all of whom had shown attacks previously, were treated for a year without symptoms. A number of volunteers at the Mississippi State Penitentiary were given a test diet consisting of wheat flour, corn meal, grits, cornstarch, white polished rice, granulated sugar, cane syrup, sweet potatoes, pork fat, cabbage, collards, turnip greens and coffee. Of the eleven convicts receiving this diet, six developed a typical dermatitis with slight nervous and gastrointestinal symptoms. The results of these investigations were not offered by the United States Public Health Service as being conclusive and incontrovertible evidence as to the etiology of pellagra, which must still be looked upon as being somewhat in doubt. The dietetic factors concerned in the production of the disease have been under serious consideration for a century or more.
This information was supplemented by a study of pellagra in the general population of the cotton mill communities in South Carolina.[248] In comparing the dietaries of pellagrous households with those of the families escaping infection it was found that the former consumed less meat, milk, butter, cheese and eggs. The value of their diet in calories and proteins was lower. The proteins contributed, moreover, were more largely from cereals, peas, beans, etc. The carbohydrate content was also lower. They concluded that the particular points involved were:—
"1. A physiologically defective protein supply,
"2. A low or inadequate supply of fat-soluble vitamin,
"3. A low or inadequate supply of water-soluble vitamin, and
"4. A defective mineral supply."
They were also of the opinion that the disease could be prevented by "including in the diet an adequate supply of animal protein foods (particularly milk, including butter, and lean meat)."
Roberts[249] in 1920 made a study of twenty-five cases of pellagra encountered in private practice. In every instance the disease developed in families provided with an abundance of food of all kinds. An analysis of the actual consumption, however, showed that "not one of the patients ate a well rounded, balanced diet of meat, milk, eggs or wholesome vegetables." Either they were suffering from a lack of nourishment in every case or they were eating practically the same diet that Goldberger used experimentally in producing pellagra.
As defined by Barker[250] pellagra "is a disease characterized by peculiar cutaneous, digestive, nervous and mental disturbances, usually running a chronic course, with periodic exacerbation, but sometimes developing acutely and proceeding quickly to a fatal termination." He speaks of the disease as developing during the winter months usually with neurasthenic manifestations—fatigability, insomnia, slight vertigo, and feelings of apprehension, followed by digestive disturbances later in the spring. The parts of the skin surface exposed to the sun develop an erythema followed by a dermatitis. Nervous and mental symptoms may appear later. In some cases the disease tends to recur every spring. The skin lesions have been described as a characteristic "mask" shown on the face, the pellagrous collar, a bandlike eruption on the neck, Casal's "necklace" extending downwards over the sternum, the pellagrous "butterfly," "gauntlets," etc. The more common digestive disorders are stomatitis and glossitis, gastric disturbances and diarrhea. Neurological symptoms observed include hyperesthesia, paresthesia, anesthesia, tremors, paralyses, muscular pains, increased reflexes and occasional convulsions.
The literature of pellagra and its associated mental disturbances has been elaborately reviewed by Babcock.[251] The following references appear in a comprehensive study of this subject made by him in 1910. Griesinger[252] described the pellagrous psychoses as characterized by a vague, incoherent delirium, accompanied by loquacity and loss of memory without any violent excitement or special disorder of the intelligence. The depression gradually develops into a torpor of all the mental powers together with muscular weakness, a condition resembling general paresis. Mongeri[253] states that the psychoses usually begin with a period of depression accompanied by hypochondriacal ideas. This is followed by confusion and hallucinations of hearing. Delusions of persecution appear, with a marked tendency to suicide by drowning. Crimes of various kinds may be caused by the paranoid condition which usually terminates in deterioration. In speaking of chronic and acute forms Bianchi[254] says: "The former is characterized by general depression, melancholia, confusion, slow dementia, paresthesias and ataxic gait. Contractures and subsulti are absent, although in most instances the reflexes are exaggerated. In the acute form we have rapid elevation of temperature, 39° to 41° C.; intense neuro-muscular excitement, subsulti, contractures, muscular rigidity, exaggerated reflexes and confusion with phases of exaltation. There are numerous intermediate forms in which we observe a great variety of psychical phenomena, and also alternations of excitement and depression. Phases of remission and of apparent recovery are observed, especially at certain seasons." Régis[255] is quoted as follows: "It is recognized that the most common form of psychosis in pellagra is mental confusion with melancholy or dreamy delirium. This occurs more or less markedly in most of the cases. It is manifested by inertia, a passivity, an indifference, a considerable torpor; by insomnia, hallucinations often terrifying, both of sight and hearing; by delirious conceptions with fixed ideas of hopelessness, of damnation, of fear, anxiety, persecution, poisoning; of possession by devils and witches, of refusal of food, and so marked a tendency to suicide, and to suicide by drowning, that Strombio gave it the name hydromania. This melancholy depression, which can reach, in certain cases, even to stupor, is always based upon a foundation of obtusion, of intellectual hebetude, and of considerable general debility, which becomes permanent and terminates by degrees in dementia, in proportion as the pellagrous cachexia makes new progress. It is accompanied sometimes by a polyneuritis. The mental confusion of pellagrins can, in place of changing directly into dementia, turn to a chronic mental confusion. One may observe in pellagra, as in every grave intoxication, a morbid state resembling general paresis (pellagrous pseudo-general paresis). This occurs especially in the cases where instead of habitual melancholy ideas, the patients present ideas of satisfaction and of wealth." Procopiu[256] found his patients "sad, apathetic, silent; in the more advanced stage they are melancholy, and fall sometimes into an absolute mutism, or respond with difficulty, and have the air of not understanding what is said to them. Sometimes this melancholy is accompanied with stupor, and leads the poor pellagrins into dementia." He also speaks of the occurrence of sudden outbursts of manic excitement. Tanzi[257] refers to the existence of both pellagrous mania and melancholia but speaks of a characteristic amentia "which manifests itself acutely in loss of time and place, loss of memory, confusion, hallucinations, and paresthesias, from which there arise morbid impulses and delusions. Pellagrous amentia, often assumes a depressive form, which simulates melancholia, and in some cases either from time to time, or throughout the whole course of the psychosis, it is accompanied by exaltation, which gives it some resemblance to mania."
Gregor[258] in 1907 made a careful analysis of seventy-two cases. He classified these in seven groups: 1. Neurasthenia; 2. Acute stuporous dementia; 3. Amentia (acute confusional insanity); 4. Acute delirium; 5. Katatonia; 6. Anxiety psychoses; and 7. Manic-depressive insanity. The neurasthenic cases (9.72 per cent) exhibited headache, pain in the gastric region, vertigo, paresthesia and lassitude, with a sense of unrest and anxiety as well as ill-defined apprehensions. There was a sense of mental incapacity and feeling of illness, together with a mild depression and hypochondriacal tendencies. The cases diagnosed as acute dementia (13.88 per cent) were of the same general type but with more advanced symptoms. These showed a decided stupor, tending to remission, deep mental depression, a sense of insufficiency and "peculiar subjective troubles." The tendency to suicide was prominent and caused this group to be called melancholia by some. Many cases showed the gradual development of an affectless stupor. Catatonic symptoms and stereotypies occasionally occurred. Memory disturbances were well marked in this form. The psychoses disappeared invariably with the symptoms of the pellagra. The Amentia group (44.44 per cent) included long-continued cases with remission and intermissions. Terrifying hallucinations and violent motor excitement appeared frequently, followed by a stupor which was sometimes interrupted by delirium. Hallucinations were usually present and some had dream states. These cases often terminate unfavorably. Acute delirium constituted 2.7 per cent of the seventy-two cases, and katatonia occurred in 13.8 per cent. These cases passed rapidly into dementia. Anxiety psychoses (4.16 per cent) were diagnosed in a few instances, but were complicated by occasional stupors. Two and seven-tenths per cent of the cases were classified as manic-depressive insanity. Mobley, according to Babcock, found the following types represented at the Georgia State Sanitarium:—1. Acute intoxication psychosis, with psychomotor suspension; 2. Infective exhaustive psychosis, with psychomotor retardation or excitation; 3. Symptomatic melancholia with psychomotor retardation; and 4. Manic-depressive psychoses.
Singer[259] in 1915 suggested the following classification of the psychoses associated with pellagra:—
1. Disorders directly due to the pellagra toxin:
(a) Symptomatic depression; (b) Delirious pictures.
2. Disorders based on peculiarities in personal make-up, the attack of "insanity" being precipitated by pellagra;
(a) Manic-depressive disorders; (b) Hysteria; (c) Psychasthenia; (d) Dementia praecox; (e) Paranoic developments; and
3. Disorders due to definite brain changes with pellagra merely as a complication:
(a) Arteriosclerotic dementia; (b) Senile dementia; (c) Presenile psychoses; (d) General paralysis of the insane.
He found mental disturbances of some kind in about forty per cent of the cases examined. As a general rule they appeared after the patient had shown evidence of several attacks of the disease. The psychoses occurred in men between the ages of twenty-one and forty and in women between forty-one and sixty. About ninety-five per cent of the mental disorders were to be attributed directly to the effect of the toxin. The remaining five per cent represented individuals with a defective nervous organization or were purely incidental complications. Singer found peculiarities in make-up associated frequently with a predisposition to pellagra. He also expressed the opinion that chronic forms of "insanity" are very rarely caused by the diseases.
Sandy[260] made a study of 160 cases at the state hospital at Columbia, South Carolina, in 1916 based on a classification of psychoses quite similar to the one now in use. He found that thirty-five per cent of these belonged to the infective exhaustive group. As a matter of fact, this is the conclusion almost anyone would reach from reading the observations of the earlier writers. These cases were usually characterized by "more or less marked delirium, being accompanied by some confusion and disorientation, there frequently being also hallucinations accompanied by more or less agitation and restlessness." Physically he found, besides well marked symptoms of pellagra, evidences of severe exhaustion, loss of weight, emaciation, fever, sordes, anorexia, and typhoid facies. "In the milder forms of these 'delirious pictures,' as Singer calls them in his contribution to the report of the Thompson-McFadden Pellagra Commission, and as he pointed out, the periods of clouding (of consciousness) may be quite brief and episodic. In such cases in the intervals when the consciousness is practically clear, the general attitude is one of symptomatic depression." Sandy found characteristic manic-depressive forms in eleven per cent of the series reviewed. The depressed types were more common. Here he found retardation of speech and action with a dearth of ideas. In these cases he looks upon pellagra as being merely an exciting etiological factor. The prognosis was not so favorable, however, as it usually is in manic-depressive psychoses, death often being due to the development of central neuritis. In three per cent of the total he found what could only be described as symptomatic depressions, the emotional condition not being so marked as one would expect in the manic-depressive group. In twelve per cent a diagnosis of dementia praecox was made. In these the pellagra was merely an incident and not an etiological factor.
In several patients Sandy found a symptom complex strongly suggestive of general paresis, thus confirming the findings of other observers. These showed speech and writing defects, absent or sluggish pupillary reaction, swaying in the Romberg position, altered deep reflexes, disorientation, memory disorders and other evidences of deterioration. The Wassermann reactions were negative in both the blood and spinal fluid tests and no lymphocytosis was shown on cell counts. These cases he thinks belong in the infective exhaustive group, and usually die of central neuritis, a condition already referred to and described originally by Turner and Meyer. Sandy also found pellagra associated with various senile psychoses. This group constituted ten per cent of those studied. Fourteen per cent of the series he left unclassified owing to lack of history, etc. Some of these showed simple deterioration, others suggested neurasthenia, and some, general paresis. Of the remaining cases three were epileptic imbeciles, three, constitutional inferiority with episodes of some kind, and three were not insane. Cases associated with chorea and hysteria were also observed. On analyzing these most important findings the assumption would seem to be warranted that pellagra is an incident in certain psychoses—(senility and dementia praecox), that it is a precipitating factor in certain cases (manic-depressive), and that the characteristic conditions due to the disease are toxic and assume the infective-exhaustive form, occasionally simulating general paresis.