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; 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. The sleep is diminished, often replaced by a dreamy state analogous to that of the infectious diseases. Primary mental confusion may be met with in four principal forms, differing in their gravity and in the predominance of one or another class of symptoms: Simple mental confusion; Delirious mental confusion; Stuporous mental confusion; Hyperacute mental confusion (acute delirium). Simple mental confusion. The essential symptoms which have been enumerated above are encountered here in their purest form. The phenomena of psychic paralysis are of a moderate degree of intensity and the automatic mental functions are unaffected. ... The patient is often more or less conscious of his condition; he observes that a change has taken place in him. "I am losing my head. . . . My mind is a blank. . . .” He perceives his mental disability and complains of being unable to gather or direct his thoughts or to evoke reminiscences—even of events that have left a very strong impression. The indecision and insufficiency of perception bring about a state of constant bewilderment. The patient. keeps repeating the same questions and the same exclamations: "Who is there?... Who has come?... Who are you?... Everything around me has changed." He does not recognize his surroundings, or if he does, it is with uncertainty. He is not certain about the identity of those about him; his bed appears queer to him, his own body seems to him to be changed, scarcely recognizable. It seems to him that his personality is going to pieces so that he no longer recognizes himself. The notion of time is impaired. The patient cannot tell whether he has been at the hospital a day or a week. In other words the patient's orientation suffers in all its elements: allopsychic, autopsychic, and temporal. The disorientation is generally more marked when the patient is away from his habitual surroundings. While, surrounded by familiar persons and objects, the patient orients himself more or less automatically, in a new place he could find his bearings only by a series of mental operations of which he is no longer capable. The reactions are slow, undecided; the movements awkward and clumsy. The mental automatism remaining intact, those mental operations which require no effort and no intervention of the will can still be properly performed. Thus one may obtain from the patient a certain number of relevant and accurate replies to questions concerning his age, occupation, residence, etc. But these replies are always given mechanically; they are brief and abrupt, and can be elicited only by putting the questions energetically and concisely. This simple, and, so to speak, schematic form of primary mental confusion is uncommon. Delirious form. This form, much more frequent than the preceding one, owes its peculiar aspect to a more or less marked exaggeration of the activity of the mental automatism, which gives rise to: (a) flight of ideas and incoherence; (b) delusions and psycho-sensory disorders; (c) more or less motor excitement. The delusions present no systematization, as for this at least a relative lucidity is necessary. They assume different forms, which often interchange in the same subject; ideas of grandeur, transformation of the personality, melancholy ideas, ideas of persecution. Painful delusions are the most common. Sometimes the ideas are absurd, like those of senile dements or of general paretics. The psycho-sensory disorders consist sometimes in agreeable, but more often in painful, illusions and hallucinations of all the senses, though most often of vision and of hearing. They may combine so as to create an imaginary world which is essentially mobile and changeable, or, on the contrary, they may exist together without any apparent correlation. Occasionally the incessant illusions and hallucinations impart to the patient a peculiar expression. Most cases described under the name of hallucinatory delirium should properly be included in this form of mental confusion. The emotional tone is variable, governed to some extent by the delusions. However, one often finds, in spite of very active delirium, a striking indifference, so that a certain discord exists between the delusions and the emotions. The motor excitement is not always due to delusions or psycho-sensory disturbances. As in dementia præcox, so also in this condition the patient may give vent to cries and motor discharges that are purely automatic and without any apparent purpose. Mental confusion of the stuporous form. Here the psychic paralysis involves not only the higher mental faculties, but also the automatic psychic functions. The limbs are motionless, the eyes dull, and the face expressionless; the mouth may be half open and the |