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.