Delusions are not infrequently the result of hallucinations. If the hallucinations of a melancholic patient consist in hearing voices which make accusatory statements, delusions of sin and unworthiness frequently follow. Hallucinations of the senses of taste and smell are almost invariably associated with the delusion that the patient’s food is being poisoned or that it consists of objectionable matter. On the other hand, many delusions are apparently the outcome of the patient’s mental state. They may be pleasant or disagreeable according as the condition is one of elevation or depression. The intensity and quality of the delusions are largely influenced by the intelligence and education of the patient. An educated man, for instance, who suffers from sensory disturbances is much more ingenious in his explanations as to how these sensory disturbances result from electricity, marconigrams, X-rays, &c., which he believes are used by his enemies to annoy him, than an ignorant man suffering from the same abnormal sensations. Loss of self-control is characteristic of all forms of insanity. Normal self-control is so much a matter of race, age, the state of health, moral and physical upbringing, that it is impossible to lay down any law whereby this mental quality can be gauged, or to determine when deficiency has passed from a normal to an abnormal state. In many cases of insanity there is no difficulty in appreciating the pathological nature of the deficiency, but there are others in which the conduct is otherwise so rational that one is apt to attribute the deficiency to physiological rather than to pathological causes. Perversion of the moral sense is common to all the insanities, but is often the only symptom to be noticed in cases of imbecility and idiocy, and it as a rule may be the earliest symptom noticed in the early stages of the excitement of manic-depressive insanity and general paralysis.
The tendency to commit suicide, which is so common among the insane and those predisposed to insanity, is especially prevalent in patients who suffer from depression, sleeplessness and delusions of persecution. Suicidal acts may be divided into accidental, impulsive and premeditated. The accidental suicides occur in patients who are partially or totally unconscious of their surroundings, and are generally the result of terrifying hallucinations, to escape from which the patient jumps through a window or runs blindly into water or some other danger. Impulsive suicides may be prompted by suddenly presented opportunities or means of self-destruction, such as the sight of water, fire, a knife, cord or poison. Premeditated suicides most frequently occur in states of long continued depression. Such patients frequently devote their attention to only one method of destruction and fail to avail themselves of others equally practicable. As a rule the more educated the patient, the more ingenious and varied are the methods adopted to attain the desired result.
The faculty of attention is variously affected in the subjects of insanity. In some the attention is entirely subjective, being occupied by sensations of misery, depression or sensory disturbances. In others the attention is objective, and attracted by every accidental sound or movement. In most of the early acute insanities the capacity of attention is wholly abolished, while in hebephrenia the stage of exhaustion which follows acute excitement, and the condition known as secondary dementia, loss of the power of attention is one of the most prominent symptoms. The memory for both recent and remote events is impaired or abolished in all acute insanities which are characterized by confusion and loss or impairment of consciousness. In the excited stage of manic-depressive insanity it is not uncommon to find that the memory is abnormally active. Loss of memory for recent but not remote events is characteristic of chronic alcoholism and senility and even the early stage of general paralysis.
Of all the functions of the brain that of sleep is the most liable to disorder in the insane. Sleeplessness is the earliest symptom in the onset of insanity; it is universally present in all the acute forms, and the return of natural sleep is generally the first symptom of recovery. The causes of sleeplessness are very numerous, but in the majority of acute cases the sleeplessness is due to a state of toxaemia. The toxins act either directly on the brain cells producing a state of irritability incompatible with sleep, or indirectly, producing physical symptoms which of themselves alone are capable of preventing the condition of sleep. These symptoms are high arterial tension and a rapid pulse-rate. The arterial tension of health ranges between 110 and 120 millimetres of mercury, and when sleep occurs the arterial tension falls and is rarely above 100 millimetres. In observations conducted by Bruce (Scottish Medical and Surgical Journal, August 1900) on cases of insanity suffering from sleeplessness the arterial tension was found to be as high as 140 and 150 millimetres. When such sleep was obtained the tension always sank at once to 110 millimetres or even lower. In a few cases suffering from sleeplessness the arterial tension was found to be below 100 millimetres, accompanied by a rapid pulse-rate. When sleep set in, in these cases, no alteration was noted in the arterial tension, but the pulse was markedly diminished.
Melancholia.—Melancholia is a general term applied to all forms of insanity in which the prevailing mental symptom is that of depression and dates back to the time of Hippocrates. Melancholic patients, however, differ Melancholia. very widely from one another in their mental symptoms, and as a consequence a perfectly unwarrantable series of subdivisions have been invented according to the prominence of one or other mental symptoms. Such terms as delusional melancholia, resistive melancholia, stuporose melancholia, suicidal melancholia, religious melancholia, &c. have so arisen; they are, however, more descriptive of individual cases than indicative of types of disease.
So far as our present knowledge goes, at least three different and distinct disease conditions can be described under the general term melancholia. These are, acute melancholia, excited melancholia and the state of depression occurring in Folie circulaire or alternating insanity, a condition in which the patient is liable to suffer from alternating attacks of excitement and depression.
Acute Melancholia is a disease of adult life and the decline of life. Women appear to be more liable to be attacked than men. Hereditary predisposition, mental worry, exhausting occupations, such as the sick-nursing of relatives, are the chief predisposing causes, while the direct exciting cause of the condition is due to the accumulation in the tissues of waste products, which so load the blood as to act in a toxic manner on the cells and fibres of the brain.
The onset of the disease is gradual and indefinite. The patient suffers from malaise, indigestion, constipation and irregular, rapid and forcible action of the heart. The urine become scanty and high coloured. The nervous symptoms are irritability, sleeplessness and a feeling of mental confusion. The actual onset of the acute mental symptoms may be sudden, and is not infrequently heralded by distressing hallucinations of hearing, together with a rise in the body temperature. In the fully developed disease the patient is flushed and the skin hot and dry; the temperature is usually raised 1° above the normal in the evening. The pulse is hard, rapid and often irregular. There is no desire for food, but dryness of the mouth and tongue promote a condition of thirst. The bowels are constipated. The urine is scanty and frequently contains large quantities of indoxyl. The blood shows no demonstrable departure from the normal. The patient is depressed, the face has a strained, anxious expression, while more or less mental confusion is always present. Typical cases suffer from distressing aural hallucinations, and the function of sleep is in abeyance.
Acute melancholia may terminate in recovery either gradually or by crises, or the condition may pass into chronicity, while in a small proportion of cases death occurs early in the attack from exhaustion and toxaemia. The acute stage of onset generally lasts for from two to three weeks, and within that period the patient may make a rapid and sudden recovery. The skin becomes moist and perspiration is often profuse. Large quantities of urine are excreted, which are laden with waste products. The pulse becomes soft and compressible, sleep returns, and the depression, mental confusion and hallucinations pass away. In the majority of untreated cases, however, recovery is much more gradual. At the end of two or three weeks from the onset cf the attack the patient gradually passes into a condition of comparative tranquillity. The skin becomes moister, the pulse less rapid, and probably the earliest symptom of improvement is return of sleep. Hallucinations accompanied by delusions persist often for weeks and months, but as the patient improves physically the mental symptoms become less and less prominent.
If the patient does not recover, the physical symptoms are those of mal-nutrition, together with chronic gastric and intestinal disorder. The skin is dull and earthy in appearance, the hair dry, the nails brittle and the heart’s action weak and feeble. Mentally there is profound depression with delusions, and persistent or recurring attacks of hallucinations of hearing. When death occurs, it is usually preceded by a condition known as the “typhoid state.” The patient rapidly passes into a state of extreme exhaustion, the tongue is dry and cracked, sordes form upon the teeth and lips, diarrhoea and congestion of the lungs rapidly supervene and terminate life.