Well described by Georget and by Delasiauve, primary mental confusion has only recently been brought again into prominence in French medical literature through the labors of Chaslin and of Seglas.1
The fundamental element of this morbid entity is mental confusion which is primary, profound, and constant.
After several days of ill-defined prodromata such as headache, anorexia, and change of disposition, the disease sets in, manifesting itself by psychic and physical symptoms.
These are the symptoms of intellectual confusion, more or less marked and more or less pure according to the gravity of the disease:
Impairment of attention;
Sluggish and disordered association of ideas;
Aboulia, characterized by constant indecision and by slowness and uncertainty of the movements.
The state of the automatic psychic functions varies according to the form of the disease: 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).
1 Chaslin. La confusion mentale primitive. - Seglas. Legons cli-niques.
The physical symptoms are constant and "are the expression of the general prostration, exhaustion, and malnutrition" (Seglas).
Loss of flesh is an early and a very marked symptom. It is caused by insufficient alimentation, digestive disorders, and defective assimilation.
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 oedema are among the manifestations of the general atony of the cardiovascular apparatus.
Appetite is lost, 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 Seglas).1
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).
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.
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 Traite de Midecine, edited by Charcot, Bouchard and Bris-saud.) Chapters on Melancholia and Mental Confusion.
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 sure of the identity of those about him; his bed appears queer, his own body seems to be changed, scarcely recognizable. It seems 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 abript, 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.