LETHARGY

LETHARGY (from Greek lethe-forgetfulness and argia-inactivity), lethargic sleep, lethargic state, apparent death, a sleep-like state of immobility that arises spontaneously or under the influence of hypnosis and lasts from several hours to several days and even weeks. The degree of depth of a lethargic attack can be extremely varied. In mild cases, only immobility with closed eyes, even breathing, and muscle relaxation is observed, and sometimes slight trembling of the eyelids and rolling of the eyeballs is noticed. At both the beginning and end of an attack, several swallowing movements are sometimes observed. From this form, a series of transitions leads to severe cases, sometimes hardly distinguishable from death, in which the physical manifestations of life become barely perceptible. In such extremely rare cases, known mainly from descriptions by older authors, breathing became so weak that it did not cause even slight moisture to appear on a mirror held to the lips, and the movements of the chest and abdominal muscles were barely noticeable; the pulse could not be felt by palpation or was extremely weak; upon auscultation of the heart, only a very weak, rhythmically fluctuating murmur was barely audible; the skin became cold and pale. Some persons in such a state showed no reaction to external stimuli, including strong painful irritations, for a long time; their pupils did not react to light or pain; their limbs were relaxed and fell quickly when lifted and then released. Such severe conditions sometimes developed in persons exhausted by external factors, such as prolonged and intense excitement accompanied by insomnia, difficult childbirth, etc. It is widely believed that some of such patients were taken for corpses and buried prematurely; however, not a single such case has been reliably established. Be that as it may, there is always the full possibility to determine with certainty the presence or cessation of life: not to mention that cardiac activity and breathing never completely cease during a lethargic attack, body temperature when measured in the rectum or vagina always maintains a significant difference from the environmental temperature, and nerves and muscles continue to contract in response to electrical stimulation. Attacks of L. usually arise suddenly, often after intense excitement, and also end suddenly. If (which happens extremely rarely) the lethargic state drags on for a long time (a week or more), the patient usually wakes up from time to time to take food or swallows when it is brought to him. As for the state of consciousness during L., according to the accounts of the patients themselves, it often remains completely preserved, so that patients perceive all impressions coming to them from the surrounding world and retain the ability to experience emotions, thus losing only the ability to make any movements. L. represents one of the diverse hysterical symptoms (Lowenfeld calls it hysterical sleep) and is a result of the activity of Kretschmer's hypobulic mechanisms, which on the one hand cause a peculiar dissociation of the will with the emergence of freed blind primitive impulses coming to the forefront, which easily in hysterical persons subordinate a number of involuntary reflex and autonomic functions (sleep, action of vasomotor centers, etc.), and on the other hand, the increased suggestibility of hysterics to random impressions. This is confirmed by the close relationship of spontaneous (self-arising) L. with the so-called lethargic stage of hypnosis described by Charcot, characterized by complete immobility, relaxation of the limbs, shallow breathing, analgesia, and relative preservation, albeit altered, consciousness. The main difference of such hypnotic L., if we do not consider its dependence on the will of the hypnotist, is the increased muscular excitability absent in spontaneous L. - L. must be differentiated on the one hand from attacks of narcolepsy, and on the other from states of hibernation in acute forms of lethargic encephalitis. In both cases, the diagnosis should be based on the presence of other hysterical phenomena and stigmata and the absence of organic symptoms. - T r e a t m e n t - primarily expectant; one must ensure the patient peace, a comfortable position, clean air, and in case of prolonged attacks-regular nutrition, above all protect him from the idle curiosity of outsiders and excessive attention from relatives.

P. Zinoviev. From a forensic medical point of view, the question of L. is significant in connection with the presumed possibility of burying alive persons in L. or in a state of minimal life (vita minima). The literature on this question is quite extensive and relates mainly to the second half of the 18th century and the first half of the 19th century, and at present the factual inadequacy of the material collected by some authors (Bruhier, 1572, and others) to prove allegedly occurring cases of burial and even exhumation of living persons has been clarified. In Germany, the question was practically addressed by the establishment of well-equipped mortuaries at cemeteries. Experience showed that in the oldest Munich mortuary, under medical supervision since 1792, there was not a single case of revival of bodies delivered there. In our legislation, a number of instructions and rules determine the procedure for examining dead bodies and autopsies; at the same time, sufficient attention is paid to the importance of establishing actual death. In particular, to determine the cause of death that occurred outside medical institutions and causes any doubts, the calling of a forensic medical expert is mandatory; in his absence, the investigative authority invites the nearest physician (arts. 63, 193 of the Code of Criminal Procedure). The autopsy period established by the rules for forensic medical examination of corpses (approved 3/1 1929) (not earlier than 12 hours) also allows for the positive establishment of the fact of death, since during this time usually clearly expressed postmortem changes (livor mortis, rigor mortis) appear. True, in some cases the opinion of a physician and the issuance of a burial permit may be required at an earlier time; sometimes for scientific and practical purposes, exhumation of bodies is allowed before 12 hours have elapsed, but not earlier than 1/2 hour after death (Rules for forensic medical examination of corpses, para. 10). In such cases, it is necessary to be guided by the earliest phenomena, which are called signs of death that has occurred; first of all, these include the cessation of heartbeat, cooling of the body below 20° (in recto), loss of muscle contractility upon irritation by electric current; to the signs of death can also be attributed the cessation of breathing, although it should be noted that usually in violent or sudden death respiratory movements stop earlier than cardiac ones (e.g., asphyxia), and therefore here one cannot speak of death having already occurred. In particular, the cessation of heartbeat and blood circulation can be established by the following methods: auscultation of the heart with a stethoscope, microphone, X-ray observation, observation of the movements of the free end of a long needle, the sharp end of which is driven through the chest wall into the heart muscle; opening a small artery; the Icarus test is also noteworthy - the introduction of a fluorescein solution under the skin or into a small vein: if there is no blood circulation, the dye is not absorbed and does not color the skin yellow and the eye proteins green. The same subcutaneous introduction of caustic ammonia is used, boiling liquids are dripped onto the skin, flies, mustard plasters are applied, and these irritations do not cause inflammatory phenomena on the corpse - redness, blisters. Thus, at present it can be stated that with proper medical supervision and the use of modern research methods, such errors as the burial of living persons are completely impossible; moreover, in case of doubt about actual death, a physician in a specific case can wait for the appearance of clear postmortem changes and signs of putrefaction (greenish discoloration of the corpse, etc.).-Further, in forensic medical practice, cases of rape of women who have fallen into L. may arise; the difficulty in evaluating such cases lies in correctly deciding whether the given person was in a state of L. during the known actions, all the more so since such statements usually come from hysterical personalities, whose testimony should be treated with caution.-As for the possibility of simulating L., careful observation of the patient by a specialist fully ensures the appropriate diagnosis.