of a lunatic who, at the beginning of a conversation, was calm and reasonable, but who, if it was continued, became excited little by little; his eyes shone brightly, his countenance assumed an expression impossible to describe, and very soon his words, his ideas, his gestures-in short, his whole appearance and all his actions-became those of a maniac in a violent paroxysm. Excitement produces a similar effect, though, of course, not to so great an extent, in many persons of perfectly sane minds. Incoherence is a prominent feature in delirium. It is generally present at some time or other in cases of acute mania, and is common in imbecility, and in chronic insanity of any kind. It appears to be directly due either to the impossibility of keeping the attention sufficiently long on one idea for its full consideration, or to a difficulty of co-ordinating those parts of the brain which are concerned in the formation and expression of thoughts so as to obtain continuity of mental action. Delirium.-Delirium is that condition in which there are illusions, hallucinations, delusions, and incoherence, together with a general excess of motility, an inability to sleep, and acceleration of pulse. The derivation of the word, de, out of, and liro, a rut or furrow, sufficiently indicates the idea entertained by the ancients of the essential nature of the condition in question. Foville' has described two species of delirium: that which occurs in acute diseases generally, and in other conditions not insanity, and that which is met with in cases of mental aberration. The first class, however, embraces many different kinds, such as the delirium of starvation, the delirium due to toxic agents taken into the system, that which follows on wounds and injuries, and that which is sometimes met with in extreme old age. However, we need not at present concern ourselves with these varieties. A few words, nevertheless, relative to the characteristics of the delirium of insanity will not be out of place. The condition may make its appearance suddenly, but usually it is of gradual development, being preceded by many signs of mental and physical disturbance. The perceptions, the intellect, the emotions, and the will may, singly or in Art. "Delire," Nouveau dictionnaire de médicine et de chirurgie pratiques, t. xi, p. 1. 1 combination, be involved. Generally speaking, illusions and hallucinations are the most prominent features, the patient being entirely aware of their true character, conversing of them rationally, and willing to take proper measures to get rid of them. Erroneous ideas are at first distinctly recognized as abnormal, he laments the emotional disturbance of which he may be the subject, and regrets that he cannot better restrain himself from perpetrating disorderly or eccentric acts. With this implication of the mental faculties there is a disposition to talk incessantly, and, of course, somewhat wildly; there is an exaggeration of motility, extravagant and excessive gestures are employed, and the patient is up and down through the day and night, now in this place and now in that, button-holing those he knows, and often those with whom he has no acquaintance, and telling them of the schemes he has in hand, or the persecution of which he is the victim. The delusion of persecution is a common phase of the disorder, and, to escape from the enemies which he imagines are conspiring against him, he may wander off unintelligently, or depart secretly for some distant place. Esquirol' has given a short description of delirium which, so far as its mental manifestations are concerned, is very accurate. "A man," he says, "is in a state of delirium when his sensations are not in relation with exterior objects, when his ideas are not in relation with his sensations, when his judg ments and his determinations are not in relation with his ideas, and when his ideas, his judgments, and his determinations are independent of his will." Delirium may be the first stage of any variety of insanity, though it is most common in the beginning of acute mania. I have seen several cases in which it was the first obvious sign of the existence of general paralysis of the insane. In one of them, the patient, a gentleman engaged in a large mercantile business, left his office at about three o'clock in order to take a drive in the Central Park. Up to that time, no one who had had any relations with him had noticed the slightest evidence of mental derangement. He drove up town in a cab, and never left it till he arrived at his own door. His wife was in the library waiting for him, but, as soon as he reached the room, she perceived that he was not right. His clothes were "Des maladies mentales," Paris, 1838, t. i, p. 5. in disorder, his eyes were extraordinarily bright, he was gesticulating violently, he was alternately laughing and crying, and she could not understand a word of his incoherent and voluble speech. From that time on the signs of serious mental disorder became more apparent, and eventually there was no doubt of the existence of general paralysis. In such cases as the foregoing, there were probably earlier symptoms, which from their lightness escaped observation, but of which the patient was himself fully aware. Although the erroneous perceptions and ideas may succeed each other with great rapidity, there is not always such a degree of incoherence as to prevent the patient being understood. Still, I think there is always some disturbance in the faculty of speech. Words are misplaced or mispronounced, or entirely forgotten, or the individual, attempting to make his articulation keep pace with his ideas, only succeeds in making himself difficult to be understood. If the patient has in his or her normal condition been musically inclined, the proclivity is very.apt to be increased in delirium, and hours are spent at the piano or some other musical instrument, or in singing at the top of the voice. Bergman' has called attention to a singular tendency, occasionally manifested by individuals in delirium, to the formation of rhymes. One case of the kind has come under my observation in which the patient, a clergyman of about forty years of age, began to show evidences of mental aberration by excitement of mind and body, and in a short time by speaking and writing altogether in rhymes, or, as he called it, "rhythmical inspiration." The following is a portion of a letter I received from him at the time he was advised to consult me: "Dear Sir: If thus you'll allow me to call you, I write to inform you that my friend Mr. Ballou "Nasse's Zeitschrift für psychologischen Aerzte," 1823, B. II, s. 419. Say at ten o'clock, if that hour suits, And if it does not, it makes little difference to me, for I shall be entirely at your disposal." I quote a few He even went so far as to prepare a sermon in rhyme, and was with difficulty prevented preaching it. lines from this production: "I see before me many a face From the lake that in fire and sulphur rolls. Waiting to seize you by the hair, And so on for thirty-one pages. Whatever we may think of the poetry of this sermon, it must be admitted that its orthodoxy is unquestionable. When he entered my consulting-room, he advanced, holding out his hand, and, with a smile on his face, said: "Good-morning, Dr. Hammond, I hope you are well, I've come a long distance my story to tell: They say I'm insane, but that's an inanity, I've a rhyming inspiration, but that's not insanity.” His whole conversation was in rhyme, or the attempt at it, for occasionally he failed to get the word he wanted, and then he would "drop into prose" for a few sentences. He lost his rhyming inspiration in a few days after I saw him, and passed through an attack of acute mania and dementia, eventually recovering and returning to his duties with his congregation. Lucid Interval.-By the term lucid interval is to be understood a condition in which there is a total cessation of the symptoms of mental aberration and a complete restoration to reason occurring between any two paroxysms of insanity. With this understanding of a lucid interval it must be regarded as a rare occurrence. In fact, it probably does not exist except in the recurrent and epileptic forms of insanity, and in certain varieties of monomania and of morbid impulses. As thus defined, it differs essentially from those remissions which occur in the violence of all kinds of mental aberration, and in which, while to a superficial observer the patient is sane, careful investigation by a skilful physician will not fail to reveal the evidences of unsoundness of mind. It is necessary to draw the line closely between these two conditions, and this is especially necessary in many medico-legal cases, in which it is important to show the state of an individual's mind at the time certain acts are alleged to have been done. Shelford' defines a lucid interval as "not a remission of the complaint, but a temporary and total cessation of it, and complete restoration to the perfect enjoyment of reason upon every subject upon which the mind was previously cognizant"; and he adds: "The determination as to the existence of a lucid interval requires attentive observation and long and repeated examination by a person acquainted with the subject of the patient's insanity." Taylor' says, with apparently less decision: "By a lucid interval we are to understand, in a legal sense, a temporary cessation of the insanity, or a perfect restoration to reason. This state differs entirely from a remission in which there is a mere abatement of the symptoms. It has been said that a lucid interval is only a more perfect remission, and that although a lunatic may act rationally and talk coherently, yet his brain is in an excitable state, and he labors under a greater disposition to a fresh attack of insanity than one whose mind has never been affected. Of this there can be no doubt, but the same reasoning would tend to show that insanity is never cured, for the predisposition to an attack is undoubtedly greater in a recovered lunatic than in one who is and has always been perfectly sane. Even admitting the correctness of this reasoning, it cannot be denied that lunatics do occasionally recover, for a longer or shorter period, to such a degree as to render them perfectly conscious of and legally responsible for their actions with other people." All this is very true, but a cure is a very different thing from a lucid interval, for the latter, properly speaking, if it "A Practical Treatise on the Law concerning Lunatics, Idiots, and Persons of Unsound Mind," London, 1833, p. lxx. 2 "The Principles and Practice of Medical Jurisprudence," vol. ii, second edition, London, 1873, p. 484. |