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drug poisoning, in conditions of exhaustion and senility, and following accidental injuries, trauma and surgical operations.

Stupor is a profound disorder of consciousness in which ordinary impressions are not comprehended and voluntary activity is suspended. The impression may be received normally but because some inhibitory process interferes with the usual mechanism no reaction takes place. The patient is aroused from this condition only by the strongest stimuli. The pulse is slow and small, the temperature is subnormal, the skin is dry, the extremities cold, the mouth is filled and overflowing with saliva, the eyes may be open but the mind does not perceive, and no voluntary movements are made.

VI. DISTURBANCES OF INTELLECTUAL FUNCTION

1. Orientation is disturbed when the patient is unable to apprehend correctly time, place and persons. He is then disoriented, for he is not able to give the day, the month and year accurately, does not recognize his surroundings and the people about him, or misidentifies them.

2. Memory may be impaired or lost. The defect may be one of retention which is shown by inability to hold or keep in mind sense impressions which have been received, or it may be a defect of recall in which the processes of association are involved and remote events and experiences are not brought back into consciousness readily or at all. Failure to retain impressions may be due to want or lack of attention to incoming impressions, so that they are only dimly perceived, or it may be due to interference of other and stronger impressions which weaken them, so that they are only faintly recorded in mind and are soon obliterated. In old age, when because of definite changes in the tissues of the brain there is a diminution or loss of plasticity, this disorder is often prominent. The same questions are asked over and over, and the identical answers repeated again and again satisfy for the moment only and seem to make no impression.

Even events which are of consequence in the life of the patient may be retained no better. A visit from some relative or friend for whom the patient has repeatedly asked, makes no lasting impression for it is out of mind almost as soon as the visit is ended, and a very short time afterwards the patient has no recollection of it. Usually in these cases his memory for remote events is unimpaired, for impressions have been retained and can be recalled.

Failure to recall or recollect may be a temporary defect, due to incomplete or faulty associations, and when the right connections are made experiences are brought back into consciousness in their entirety and often vividly; or it may be a permanent disorder due to a complete interruption of connections and associations and the patient is unable either to recall experiences or to recognize them as belonging to his past when they are recalled to him. Amnesia is a term which is applied to this condition.

Paramnesia has been defined as an "illusion of memory," for the person is unable to distinguish between real and imaginary memory. This may be due to faulty observation and attention whereby impressions are not clearly perceived and are therefore indistinct and become confused in memory, and when recalled the details of one experience become confounded with those of another. This condition is present in normal individuals, for some of the untruths of every day are of this type, and in some mental patients the condition is greatly exaggerated and they falsify in the most extraordinary manner, relating not only what is not justified by the facts, but what is grossly contradictory to the truth.

Fabrication is the invention or creation of fictitious events in order to make explanations adequate. When memory does not serve and details and intervening events are not recalled, the story or recital is made complete by weaving in fancied or imagined events to fill the gaps. Fabrication is often stimulated by questions, for the patient quickly grasps the idea contained in the question and makes it a part of the experience.

Aphasia is a term which is applied to certain disturbances of function in the cerebral centres which have to do with language. These disorders are the result usually of some lesion which either interferes with or destroys the function of those centres where impressions of written and spoken words and their expression are stored in memory, and may be either sensory or motor. Sensory aphasia is shown by inability to comprehend spoken and written words. The patient can hear and can see, but does not understand. He is like one who hears a foreign language which is unfamiliar, or looks at symbols whose meanings are unknown; he cannot understand because there are no images in memory which correspond to what he hears and sees, and so he cannot interpret them. The ability to recognize objects or recall their uses may also be lost. This disorder is not uncommon among the aged, and articles and objects of everyday familiarity are sometimes put to most unusual and unsuitable uses.

Motor aphasia is shown by inability to speak or to write words with which one has been familiar. The patient knows well what he wants to say or to write and recognizes the word when it is suggested to him, but because the memory of muscular control and coördination required to speak or to write the words is lost, he cannot express them. He has been likened to a banker who wants to open his safe and has lost the combination. ("Essentials of Medicine," Emerson, p. 188.)

3. Thinking. The processes involved in thinking may be so interfered with or impaired that any real mental activity seems to require unusual effort and strain, and concentration becomes especially difficult. This is spoken of as mental tension. This disorder is usually brought out by the physician in the mental examination by asking the patient to write spontaneously and to dictation, and to make some of the more difficult calculations which test the ability to think and to concentrate.

4. Intelligence may be impaired or defective. This condition is made evident by a limited or inadequate grasp

in matters of general information, facts of common knowledge and the special knowledge of the environment, occupation, trade, etc. This condition may be due to lack of educational opportunity and training, to the psychosis and to constitutional defect. When the impairment is confined to the period of the psychosis, the general knowledge gained before the onset of illness may be good. When the defect is shown to be constitutional it is, of course, permanent, and is termed mental deficiency. The various psychometric tests are largely employed to disclose the degree of deficiency and to establish the permanent intellectual level.

VII. JUDGMENT

Impairment of judgment is shown by lack of insight. The patient fails to have any realization of his condition, and when gravely ill may declare he is all right, and deny that he has any trouble in any way.

CHAPTER VII

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THE ADMINISTRATION OF FOOD-RELIEF OF INSOMNIA - PREVENTION AND TREATMENT OF BED SORES PREVENTION OF DISTENTION OF THE BLADDER AND COLON - MANAGEMENT OF CONVULSIONS HANDLING OF EXCITED PATIENTS AND CARE OF SUICIDAL PATIENTS

Early in the care of patients mentally ill, the nurse is beset with conditions and situations whose import must be quickly recognized, and which must be promptly relieved, many times without the assistance which a physically ill patient can always give, and frequently against the strong opposition of the patient. Some of the more difficult conditions and situations which confront, perplex and test the ingenuity and resourcefulness of the nurse, have to do with the administration of food, the relief of insomnia, the prevention and treatment of bedsores, the prevention of distention of the bladder and colon, the management of convulsions, the handling of excited patients and the care of those with suicidal tendencies.

The administration of food. One of the most important duties of the nurse is to have the patients under her care take a sufficient amount of nourishing food. To accomplish this is often a difficult and perplexing problem, for many mental patients will not eat, and resist all efforts of the nurse to have them do so. This does not, however, lessen her responsibility, for every patient must take a reasonable amount of food, unless orders to the contrary have been given by the physician. She should find out, if possible, the reason food is refused, that she may better know how to proceed and what to do. Often it is due to delusions

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