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.