CHAPTER XVIII. MISCELLANEOUS GROUPS (Continued). PSYCHOSES OF AUTOINTOXICATION: URÆMIC URÆMIC delirium presents the usual features of toxic deliria: more or less complete clouding of consciousness, disorientation, phenomena of psychic automatism, among which psycho-sensory disorders occupy a prominent position. The delusions, the emotional tone, and the reactions enable us to distinguish two principal forms of uræmic delirium: an expansive form and a depressed form. Expansive form.—The patient is a great personage, a general, a prince; he assists at a grand review, gives commands to his officers, or orders sixteen horses to be harnessed to his carriage; the Pope presents him with the imperial crown. Often the delirium takes a mystic form: the heavens open, celestial music is heard, or angels descend on an immense ladder as in Jacob's dream. Depressed form.-Melancholy ideas combine with ideas of persecution and hallucinations of an unpleasant character. The patient imagines people are searching for him to drag him to the scaffold; the house is on fire; an odor of sulphur is diffused through the air. Whatever the form of delirium, the reactions are often very powerful and give rise to violent, at times terrible, agitation. Often, also, in the depressed and mystic forms, there is marked stupor with a tendency to cataleptoid attitudes.1 As to the development of the attack, we distinguish an acute form characterized by severe symptoms: intense agitation or, on the contrary, profound stupor, incessant hallucinations, extreme confusion with clouding of consciousness, etc.; and a subacute form characterized by symptoms of lesser intensity and by periods of comparative lucidity alternating with delirious periods. In some exceptional cases of uræmic delirium of the subacute form the delusions become systematized and may thus be misleading in the diagnosis. The mental symptoms of uræmic delirium present no pathognomonic features and are merely a manifestation of poisoning of the cerebral cells. The diagnosis must be made from the accompanying somatic symptoms: convulsive attacks, cardiovascular disorders, dyspnoea, œdema, pupillary manifestations,-myosis and paresis of the pupils, diminution of the specific gravity and of the toxicity of the urine, albuminuria, anuria, oliguria, or polyuria. Uræmic delirium is often very similar to delirium tremens. It seems that the two affections may even be combined. Brault 2 is of the opinion that uræmia, like traumatism or pneumonia, may act as the exciting 1 Brissaud. De la catatonie brightique. Sem. méd., 1893.Cullerre. Sur un cas de folie urémique consécutif à un rétrécissement traumatique de l'urèthre. Arch. de neurol., Vol. XXVII, No. 89. 2 Traité de médecine. Charcot-Bouchard. Maladies des reins. cause of an attack of delirium tremens. We have already seen how much importance is attributed by some authors, notably by Herz, to uræmia as a pathogenic factor in delirium tremens. The prognosis depends upon the severity of the somatic disturbances. The treatment is that of uræmia in general: milk diet, blood-letting, purgatives, and diaphoretics. CHAPTER XIX. MISCELLANEOUS GROUPS (Continued). THYROGENIC PSYCHOSES. DESTRUCTION of the thyroid gland gives rise to a peculiar autointoxication which is met with in two different clinical forms: myxedema and cretinism; in the former the destruction of the gland occurs at an adult age, in the latter it occurs in infancy. § 1. MYXOEDEMA. The external aspect of a myxedematous patient is characteristic. The puffed and expressionless face together with the general attitude reflect both the mental inertia and the profound disorder of general nutrition. Psychic disturbances. These consist chiefly in symptoms indicating a blunting and torpor of cerebral activity, -psychic paralysis; there is extreme sluggishness of association of ideas demonstrable by simple clinical examination as well as by psychometry; the attention is difficult to obtain and to fix; there are also retrograde amnesia by default of reproduction and anterograde amnesia by default of fixation; permanent indifference; aboulia. The indifference is occasionally interrupted by transient attacks of irritability. Myxoedematous patients are often sulky and ill-natured. Physical disturbances.-The sleep is diminished, replaced by permanent somnolence, and disturbed by nightmares. The reflexes are diminished or completely abolished; all movements are sluggish, awkward, and clumsy. But the most interesting disorders are those of the integuments and of the thyroid gland. Integuments. The skin is thickened and infiltrated; its surface is smooth and of a dull whiteness. On palpation it gives the sensation of waxy tissue. There is no pitting on pressure, this being a point of distinction between myxedematous infiltration and ana sarca. The features are dulled, the eyes sunken, and the lips thickened; the wrinkles of the forehead disappear, and the naso-labial fold becomes effaced. The physiognomy is immovable and stupid. The hair of the head, eyebrows, and beard is scant, discolored, and atrophied. These characteristics are pathognomonic of the myxodematous facies. The hair over the entire body is atrophied. The nails become deformed and brittle. The mucous membranes present thickening analogous to that of the skin. They are pale, anæmic, and in places cyanotic. Thyroid gland.-On palpation one finds atrophy or even complete disappearance of the gland. Sometimes the thyroid gland is increased in size, causing an abnormal prominence in front of the neck. |