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ACUTE  INSANITIES                                                    377

symptoms  are  the  development   of  hallucinations   of   an  auditory   nature
followed by dreadful obsessions, delusions and loss of self-control.

2. The Acute Stage of Onset.—The physical symptoms of this stage are
loss of appetite, nausea and vomiting. The heart is irritable, beating
rapidly and irregularly. The arterial tension increases as the physical com-
plaints become more acute. The skin is moist and greasy from frequent
profuse sweats, and is often affected by pustular eruptions. Sleeplessness
is almost a constant symptom. The senses of taste and smell are commonly
affected, but not those of sight and hearing, though hallucinations of a visual
and auditory nature are often present in this stage. The sensations of
touch, pain and warmth are generally diminished. The pupils are sluggish
and dilated. The visceral reflexes not being under control, the patient, as a"
rule, passes urine and faeces involuntarily; hence he has to be watched
constantly. The superficial and deep reflexes are markedly increased. The
voluntary muscles are usually rigid and stiff. This condition may last from
a few minutes to a few hours.

The mental condition is chiefly one of confusion and restlessness. The
patient is largely affected by paroxysmal hallucinations of an auditory
nature, characterized by dreadful persecutions from imaginary enemies, to
avoid whom he may try to conceal himself or may commit suicide. During
the periods when the patient is not disturbed by these hallucinations, he
may close his eyes and lie quiet, listless and apathetic for hours without
taking heed of his surroundings; or he may appear sane, though confusion
of thought, loss of memory and want of the power of fixing attention are
generally present.

This, stage lasts for four to six weeks, and is then followed by an attack
of fever or increased leucocytosis which brings on the third stage. The
acute stage may, however, end in death from exhaustion or from some
toxsemic" condition.

3. ,/The Stage of Stupor.—During this stage the physical symptoms are
the persistence of gastric disturbances with obstinate constipation. Sleep is
excessive and causes the patient to be drowsy and heavy. The arterial
tension is low. Circulation is slow and feeble ; hence the extremities are
cold, blue and frequently cedematous. There is an offensive odour from the
skin, which is greasy. The muscles are very rigid, and the patient may
assume uncomfortable attitudes. Strong resistance is encountered when -am
attempt - is made to extend the contracted limbs. If a limb is, however,
placed in a forced position, it may remain in that condition for an indefinite

Mentally, the patient passes into a'semi-conscious, stuporous condition.
He sits or stands and does not show any signs of spontaneous movement.
An attempt at feeding or dressing him is very strongly resisted by the
patient. He does not even answer questions put to him. He generally
assumes a state of mutism but may, all of a sudden, start repeating auto-
matically some inarticulate syllable, word,. number, phrase or sentence for
hours (verbigeratiori). The patient sometimes repeats the words spoken
to him or imitates the tone of one whom he has heard speaking (echolalia) *
Hallucinations of sight and hearing develop, and give rise to delusions of a
varied nature. The patient may suddenly be, attacked by a maniacal fit,
when he may have a suicidal or homicidal tendency. During this period it
is very essential to watch him closely.

The duration of the stage is uncertain; it may be from a few weeks to
a few years. Recovery occurs in a very small number of cases.

4, The Stage of Excitement.—The stuporous condition is followed by
the stage of excitement. In many cases there is an apparent recovery