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.