lirium proper) which can only be explained by a toxic action.

After the description of febrile delirium I shall say a few words with regard to infectious delirium proper.

Febrile delirium. In the mental disorders of febrile origin three degrees of intensity can be schematically distinguished.

In the slightest degree of intensity the disorder is limited to slight mental torpor and irritability.

In the second degree there is disturbance of ideation. The remarks of the patient become disconnected, and are characterized by a peculiar monotony suggestive of a fixed idea. Ten times in succession he will ask whether the cupboard is properly locked, or whether such and such a matter has been attended to, or whether some particular note has been duly paid. At the same time some illusions, chiefly affecting vision, make their appearance. It seems to the patient that someone is in hiding behind the curtains, that the furniture in the room has assumed peculiar shapes. He does not recognize the voices of those about him and confounds them with each other. All these phenomena the patient is more or less conscious of. He realizes, either spontaneously or from the remarks made by those about him, that he is mistaken, "that he is raving, that he no longer knows what he is talking about." He is in a state of indefinable uneasiness and is apt to become somewhat restless, especially at night. He feels ill at ease in his bed, tosses from side to side, asks to get up.

Finally, in the third degree of intensity we have true delirium. This consists essentially in more or less profound clouding of consciousness combined with vague delusions, multiple psycho-sensory disorders, and motor excitement which is at times very marked.

The delirium is essentially variable and mobile, at time pleasant, at others painful; the psycho-sensory disturbances are of the combined form with a predominance of illusions and hallucinations of sight. The images and scenes follow each other as in a dream, of which they seem to be a continuation (dream delirium). The patient imagines he is in the country, in a theater, in a church; pompous processions march past him amidst the sounds of music and the perfume of flowers and censers; he converses with imaginary persons, defends himself against assassins, rejects a glass of milk offered him, thinking that it is poison. Often under the influence of his hallucinations he strikes at the air and attempts to get out into the street or to pass through the window, which he takes for the door.

However, as during a dream, the subject may by a sudden and energetic call be transported from his imaginary world into the real one. Such periods of lucidity are in general but transitory.

Often, chiefly in the beginning of all forms and through the entire course of the mild forms, the delirium disappears in the morning to reappear in the evening and to last during a portion of the night.

The prognosis depends less upon the intensity of the delirium than upon the physical symptoms which accompany it. As a rule all febrile affections com

plicated by intense delirium should be considered grave.

In fatal cases the delirium gradually subsides and coma replaces the excitement.

Febrile delirium, like acute alcoholic intoxication, is an excellent criterion for judging the resistance of the brain: the greater the predisposition to mental disorders the more likely it is for delirium to occur under such circumstances. Like alcohol, the microbic poisons and the toxic products of the organism act most readily upon brains the equilibrium of which is least stable and therefore most easily disturbed.

The treatment is that of the infectious disease. Strict watching is indicated. Cold baths are often very efficacious in relieving the mental disorders.

Infectious delirium proper. Kraepelin and Aschaffenburg have described under the name of infectious delirium mental disorders which supervene in the course of an infection without the fever being particularly intense or even before any fever has appeared (Initialdelirium).

Infectious delirium is met with chiefly in typhoid fever, in variola, and in typhus fever. The symptoms sometimes take the form of maniacal excitement, more often that of acute confusional insanity or of hallucinatory delirium.

CHAPTER XVI.

MISCELLANEOUS GROUPS (Continued).

PSYCHOSES OF EXHAUSTION: PRIMARY MENTAL CONFUSION, ACUTE DELIRIUM.

WELL described by Georget and by Delasiauve under the name of "Stupidity," primary mental confusion has only recently been brought again into prominence in French medical literature through the labors of Chaslin and of Séglas.1

The fundamental element of this morbid entity is mental confusion which is primary, profound, and

constant.

Essential symptoms. After several days of illdefined prodromata such as headache, anorexia, and change of disposition, the disease sets in, manifesting itself by psychic and physical symptoms.

A. Psychic symptoms. These are the symptoms of intellectual confusion, more or less marked and more or less pure according to the gravity of the disease:

Clouding of consciousness;

Impairment of attention;

Sluggish and disordered association of ideas;
Insufficiency of perception;

Aboulia, characterized by constant indecision and

by slowness and uncertainty of the movements.

1 Chaslin. La confusion mentale primitive. Séglas. Leçons cliniques.

The state of the automatic psychic functions varies according to the form of the disease: the mental automatism may be relatively unaffected (simple mental confusion), exaggerated (delirious mental confusion), or paralyzed, like the higher mental functions (mental confusion of the stuporous form).

B. Physical symptoms.-The physical symptoms are constant and "are the expression of the general prostration, exhaustion, and malnutrition” (Séglas).

Loss of flesh is an early and a very marked symptom. It is caused by insufficient alimentation, digestive disorders, and especially by defective assimilation of nutritive matter.

Fever sometimes exists, chiefly at the onset; in some cases, especially in the stuporous form, there may be subnormal temperature.

A small low tension pulse, feeble and at times irregular heart sounds, sluggishness of the peripheral circulation, cyanosis of the extremities, and œdema are among the manifestations of the general atony of the cardiovascular apparatus.

The appetite is abolished, the tongue coated; the process of digestion is accompanied by painful sensations; constipation is often present and is very obstinate.

Frequently there is slight albuminuria. The toxicity of the urine is often increased, this being dependent on the presence of certain ptomaines in the urine (Ballet and Séglas).1

1 For a bibliography bearing on the changes in the urine in mental confusion and in the psychoses in general, see Ballet. Les psychoses. (Article in Traité de Médecine, edited by Charcot-Bonchard and Brissaud.) Chapters on Melancholia and Mental Confusion.