A system of practical medicine. By American authors. Vol. 5

by Unknown

(a) Ideal delusions are false ideas or concepts arising more or less spontaneously, or by morbid association in the subject's mind. For example: he believes that he is a god, that he has millions of money, that his soul is lost, that he has a thousand children, etc. Many of the delirious ideas experienced by insane patients are delusions, and so to a certain extent (subject to temporary corrections by reasoning and demonstration) are the notions of hypochondriacs about their health.

(b) Sensorial delusions are such as are founded upon illusions and hallucinations. The moment a subject is convinced of the reality of an illusion or hallucination, believes in its actuality, he is said to have a delusion. The change from illusion and hallucination to the state of sensorial delusion indicates a deeper psychic alteration—a failure of critical capacity or judgment. Examples: A man imagines the stump of a tree in front of him to be a human being, but by reasoning, by closer visual inspection, or by palpation he concludes that it is a tree, after all; this is a simple illusion. If he persists, in spite of argument and demonstration, in his assertion that the stump is a human being, he is said to have a delusion or to be deluded. If a person sees wholly imaginary flowers or hears imaginary voices, as long as he is capable of recognizing the falsity or want of actuality of these images or sounds he has a simple hallucination; if he ceases to make the necessary correction, and believes the flowers and voices to really exist, he has sensorial delusions. It should be borne in mind that sane persons may have hallucinations, and that some insane have no sensorial delusions; also, that some insane are capable of correcting, for a time at least or when closely questioned, their illusions and hallucinations. Apart from these exceptional conditions, delusions, sensorial and ideal, are most important symptoms of insanity. We also meet temporary delusions in toxic conditions (from Indian hemp, alcohol, etc.) and in the delirium of acute general disease, of low febrile states, starvation, etc. Delusions are sometimes named in groups, according to the prevailing type of mental action; then, we have exalted delusions, in which the false notions and beliefs are rose-colored or extremely exaggerated (as in paralytic dementia, etc.). Again, we speak of delusions of persecutions, where the patient fancies himself pursued, maltreated, insulted, or where he insanely follows up and persecutes others. Such classification is useful for purposes of clinical and psychical study.

Imperative conceptions or controlling morbid ideas and desires are ideal delusions presenting certain peculiarities; one of which is that of growth by accretion and assimilation by a sort of false logic and grotesque analogical reasoning, until from a mere fancy or notion the growth invades and governs the entire subjective life of the subject.

VIOLENCE is a complex symptom always deserving of study and psychological analysis. It may present itself as an increase of a naturally bad disposition or as a wholly new exhibition of irritability and temper. Beyond these limits it may assume the shape of abusive and foul language (not before employed by the subject), or of physical acts of a destructive or dangerous character. Viewing the condition from a psychological standpoint, we should endeavor to distinguish between merely impulsive or animal violence due to over-activity of the emotional state or to a loss of self-control (cortical inhibition), and quasi-deliberate acts due either to special delusions or to delirium. Abnormal irritability, or increase in an originally bad temper, is met with in hysteria, neurasthenia, and partial dementia. Masturbators and epileptics frequently exhibit this condition. In a state less pathological, from mere fatigue or overwork, irritability may temporarily show itself as a result of reduced cortical energy; and in such cases rest, a cup of tea or coffee, alcohol, or even ordinary food, restores good-nature and equanimity as by magic. In little children bad temper is a frequent precursor of illness, more especially of cerebral disease. Greater degrees of violence in speech and acts are met with in hysteria, neurasthenia, and in many forms of insanity, in the guise of exaggerations of animal propensities, to make a noise, break objects, injure persons in an aimless general way. Voluntary or quasi-voluntary acts of violence are those which are done under the influence of hallucinations, delusions, or of delirious ideas, usually by insane patients. The delirium of acute or inflammatory disease or of the typhous state is rarely active, although pericarditis sometimes gives rise to very violent delirium, and the mild delirium with picking and gesticulating of pneumonia, typhoid fever, etc. may sometimes simulate mania. In general terms, the words and acts of patients represent the ideas passing through their minds in a rapid confused way, much as in dreams. Violence done under the influence of clearly-defined hallucinations and delusions is most dangerous, because it is executed with apparent deliberation and volition. Thus, a man laboring under hallucinations of hearing, fancying himself insulted, may turn in the street and strike or shoot some one near him, the supposed author of the insult. An epileptic falls in a partial attack or has epileptic vertigo; as a part of the seizure there is a dream-like scene of assault, actual or threatened, upon him, and on rising from the ground, or after the momentary vertigo the patient, acting in accordance with the demands of the dream-like scene, makes an onslaught upon those near him or smashes furniture, etc. Seeing such acts, without knowing their genesis, one is liable to consider them normally deliberate and malicious. On recovering consciousness (which may not be for several hours or days) the epileptic patient appears utterly oblivious of his actions, and is much astonished to learn what he has done. In many cases of insanity violent acts are done through a similar psychic mechanism—i.e. through the domination of delusions. Delusions often give rise to what may be termed negative violence—resistance to personal care, treatment, giving of food, etc. This is exemplified in acute melancholia, with overpowering fears of all kinds and terrorizing hallucinations of sight and hearing. The patients crowd in corners or sit curled up, and resist with all their might whatever is done for them, even striking and biting the attendants.

Therapeutically, the question of physical restraint or non-restraint in the management of violence might be discussed here, but the question is one which can be much better considered in connection with the general treatment of insanity, and the reader is consequently referred for information to the article on that subject.

DELIRIUM is a term which has been so variously applied that a brief definition of it is wellnigh impossible. Illogical or unreasoning and incoherent thoughts expressed in words and acts may suffice to give a general idea of the condition. Extreme applications of the term are, for example, to say that in a case of extreme dementia the rambling, disconnected talk is delirium, or that in certain forms of monomania the expression of the patient's peculiar delusion is delirium. It seems to us that there should be a certain degree of activity in the production of morbid ideas, with confusion in their expression, to justify the use of the term delirium. Again, in some instances the delirious talking and acting are only the reflex of abundant hallucinations of various senses which beset the patient. In some other respects the term delirium is applied in several distinct ways: first, in a substantive form as a designation for the incoherent words and acts of a patient. Usually, it is then put in the plural form of deliria. Thus we have the more or less highly organized, fixed or changeable deliria of monomania, chronic mania, melancholia, paretic dementia, etc., and the confused and evanescent deliria of acute general diseases, intoxications, and many forms of insanity. In short, we may speak of a sick person's deliria as we would of a normal person's thoughts; or in still more elementary analysis deliria are abnormal or insane thoughts and corresponding action. Second, delirium is used adjectively as designating certain diseases—e.g. delirium tremens, delirium a potu, acute delirium, delirium of acute diseases, etc. The seat of the psychic processes which go to make delirium is undoubtedly the cerebral cortex. This view is supported partly by the clinical consideration that delirium bears a certain relation to the psychic development of the subject. Thus, we see in children and in the higher animals rudimentary or fragmentary deliria; in advanced age the delirium is feeble and wellnigh absent; while in ordinary adults with well-developed cerebration deliria are abundant and varied. From pathological anatomy we learn that deliria become simplified and subside in proportion as the cerebral cortex becomes more and more damaged by effusions, by pressure effects, or by degenerative changes. As to the relation between special histological pathological changes, our knowledge is small and to a certain extent paradoxical. Thus, it is universally admitted that delirium may be due either to hyperæmia or to anæmia of the brain. The delirium of alcoholic or cannabis intoxication may be fairly assumed to be of sthenic or hyperæmic origin, either by the nervous elements themselves being in an exalted state of irritability, or because an increase in the circulation of arterial blood in the brain leads to greater activity of the cellular elements. Again, delirium appears in conditions of general or cerebral anæmia, as in starvation, after prolonged fever, after the withdrawal of customary stimuli, etc. These views are confirmed by the fact that some deliria cease upon the administration of sedatives and narcotics, while others are relieved and cured by rest, stimulants, and food. On the other hand, a large class of deliria, as exhibited in the insane, escape pathological analysis; for example, the delirious conceptions of monomania occurring in apparent somatic health and without well-marked symptoms of cerebral disease. We are much in the dark as to what the processes may be by which delusional notions grow in the subjective life and manifest themselves outwardly as deliria. It is probable that in such cases there is no material lesion (appreciable to our present means of research), but a morbid dynamic condition, false reactions, abnormal centripetal and centrifugal associations in the psychic mechanism, with or without inherited bias. The diagnosis of delirium as a symptom is usually easy, but it is a task of no small difficulty to determine its pathological associations in a given case, and to draw from this study correct therapeutic indications. A careful review of the antecedent circumstances, of the patient's actual somatic condition, more especially as regards hæmic states and vaso-motor action, is indispensable.

LOSS OF CONSCIOUSNESS, COMA.—Suspension of all sensibility, general and special, with loss of all strictly cerebral (cortical) reflexes, is met with in many pathological states. Its physiology or mode of production is unknown, but there are good reasons for believing that the lesion, vascular or organic, affects chiefly the cortical substance of the hemispheres. Its clearest manifestation, clinically, is after depressed fracture of the skull or after concussion of the brain, without or with abundant meningeal hemorrhage. In the last case unconsciousness or coma appears as an exaggeration of drowsiness or stupor; after a fall the patient may be able to walk into the hospital, but soon becomes drowsy, then stupid, and lastly completely insensible. In the first case, that of depressed fracture of the skull, the raising of the depressed bone is often followed immediately by return of consciousness; the patient seems to wake as from a deep sleep. In medical practice there are many analogous conditions of abnormal pressure causing coma, as in meningitis, cerebral abscess, hemorrhage, embolism of cerebral vessels, etc. Long-continued or fatal coma may be caused by general morbid states, as uræmia, acetonæmia, surgical hemorrhage, intoxication by narcotics, alcohol, ether, etc., and by asphyxia. Momentary loss of consciousness is induced in the various forms of epilepsy, lasting from a fraction of a second (so short as not to interrupt walking) to one or two minutes, followed by the more prolonged coma of the asphyxial stage. Temporary unconsciousness is also caused by physical or moral shock, but in many such cases the heart is primarily at fault, and the condition is termed syncope. Although in practice it is most important to distinguish syncope from more strictly cerebral coma, yet it must be admitted (and such admission is important for therapeutics) that in both categories of cases anæmia of the brain (cerebral cortex) is the essential factor or immediate cause of suspension of consciousness. This view of the pathology of coma is borne out by the fact that the condition may be produced at will, experimentally or therapeutically, by compression of both carotid arteries. It may be well to mention here the pseudo-coma of hysteria. In these cases consciousness is really present, as shown by responses to violent cutaneous irritations (faradic brush), by quivering of the closed eyelids and resistance to attempts to open them, by vascular or muscular movements evoked by remarks of a flattering or abusive nature made in the patient's hearing, and by cessation of the condition after complete closure of the nose and mouth for forty-five seconds or one minute (asphyxia). In the typically unconscious state, as in cases of fracture of the skull or of intracranial pressure by exudations, clots, tumors, etc., there are several objective symptoms to be noted. The pupils are usually dilated and immovable (exceptions chiefly in narcotic poisoning); the pulse is reduced in frequency and retarded; it is sometimes full and bounding, or in other cases feeble and irregular. The breathing is often slow and irregular; the patient fills out his cheeks and puffs (smokes the pipe); sometimes the Cheyne-Stokes type of respiration is observed. In hysterical or hypnotic impairment of consciousness these important symptoms are absent: the patient seems simply asleep. Although coma is, strictly speaking, a symptom, it so often appears as the leading one of a group that it deserves study almost as a disease. Indeed, there are few more difficult problems for the physician than the case of a comatose subject without a good history of the preceding condition, causes, etc. It is impossible here to consider all the possibilities of this problem in diagnosis;¹ we can only state the chief and most probable pathological conditions which may cause coma.

¹ An able attempt at the differential diagnosis of comatose cases, by J. Hughlings-Jackson, will be found in Reynolds's System of Medicine, Am. ed., 1879, vol. i. p. 920.

(1) The patient may be epileptic. The following signs of a past convulsive attack should be sought for: a bitten tongue, fleabite-like ecchymoses on the face, neck, and chest, saliva about the face and neck, evidences of micturition or of seminal emission in the clothing, etc. There is usually a small rise of temperature after a single fit, and consciousness soon returns without assistance, or a second seizure appears.

(2) The patient may be suffering from surgical cerebral compression or concussion. Signs of injury about the head or other parts of the body, oozing of blood or sero-sanguinolent fluid from the ears and nose, will sometimes clear up the diagnosis. Especially suggestive of meningeal hemorrhage is a gradually increasing stupor without distinct hemiplegia.