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Physicians sooner or later discover, through clinical experience, the need for special competence in assessing the mental faculties of their patients They must be able to observe with detachment and complete objectivity the patient s intelligence, memory, judgment, mood, character, and other attributes of personality in much the same fashion as they observe the patient s nutritional state and the color of the mucous membranes The systematic examination of these intellectual and affective functions permits the physician to reach certain conclusions regarding the patient s mental status and its relationship to his illness Without such data, one cannot judge the reliability of the history and an incomplete picture of the illness is obtained; this, in turn, leads to errors in the diagnosis and treatment of the patient s neurologic or psychiatric disease Perhaps the content of this section will be more clearly understood if a few of the introductory remarks to the later section on psychiatric diseases are anticipated here The main thesis of the neurologist is that mental and physical functions of the nervous system are simply two aspects of the same neural process Mind and behavior both have their roots in the self-regulating, goal-seeking activities of the organism, the same ones that provide impulse to all forms of mammalian life But in addition, the prodigious complexity of the human brain permits, to an extraordinary degree, the solving of dif cult problems, the capacity for remembering past experiences and casting them in a symbolic language that can be written and read, and the planning for events that have yet to take place The constant but sometimes meandering internal verbal experience of this ideation during waking was aptly named stream of thought by William James Somehow there emerges in the course of these complex cerebral functions a continuous awareness of one s self and the operation of one s psychic processes It is this continuous inner consciousness of one s self and one s past experiences and ongoing cognitive activities that is called mind Whether this is an emergent property of various mental functions or simply their representation cannot be answered, but any separation of the mental from the observable behavioral aspects of cerebral function is probably illusory Biologists and psychologists have reached this view by placing all known activities of the nervous system (growth, development, behavior, and mental function) on a continuum and noting the inherent purposiveness and creativity common to all of them The physician is persuaded of the truth of this view through daily clinical experience, in which every possible aberration of behavior and intellect appears at some time or other as an expression of cerebral disease Further, in many brain diseases, one witnesses parallel disorders of the patient s behavior and a dissolution or distortion of the introspective awareness of his own psychic capacities The reader will nd that in this section of the book, s 20 and 21 are concerned with common disturbances of the sensorium and of cognition, which stand as cardinal manifestations of certain cerebral diseases The most frequent of these are delirium and other acute confusional states as well as disorders of learning, memory, and other intellectual functions A consideration of these abnormalities as a rule indicative of a general disturbance of cerebral function leads naturally to an examination of the symptoms that result from focal cerebral lesions (Chap 22), and of derangements of language (Chap 23) As emphasized in the following chapters, even these disturbances often fall between the.

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6:

readily localizable functions of the cerebrum and those that can be assigned only broadly to specialized regions of the brain The psychiatric causes of disordered thinking and behavior have special qualities that make them separable from most of the conditions considered in the next several chapters They are discussed in Chaps 56 to 58

The striking event in which a patient with previously intact mentality becomes acutely confused is observed almost daily on the medical, surgical, and emergency wards of a general hospital Occurring, as it often does, during an infection with fever or in the course of a toxic or metabolic disorder (such as renal or hepatic failure) or as an effect of medication, abused drugs, or alcohol, it never fails to create grave problems for the physician, nursing personnel, and family The physician has to cope with the problem of diagnosis, often without the advantage of a lucid history, and any program of therapy is constantly threatened by the patient s inattention, agitation, sleeplessness, and inability to cooperate Nurses are burdened with the need to provide satisfactory care and a safe immediate environment for the patient and, at the same time, maintain a tranquil atmosphere for other patients The family must be supported as it faces the frightening specter of a deranged mind and all it signi es These dif culties are greatly magni ed when the patient arrives in the emergency ward, having behaved in some irrational way, and the physician must begin the clinical analysis without knowledge of the patient s background and underlying medical illnesses It is our view that such patients should be admitted to a general medical or neurologic ward and not to a psychiatric unit, which often lacks the wherewithal to properly investigate and manage the great variety of medical diseases that cause the acute confusional state Transfer of the patient to a psychiatric service is undertaken only if the behavioral disorder proves impossible to manage in a general hospital service, or, if warranted, when the underlying medical problems have been identi ed and a program of treatment has been started

The de nition of normal and abnormal states of mind is dif cult because the terms used to describe them have been given so many different meanings in both medical and nonmedical writings Compounding the dif culty is the fact that the pathophysiology of the confusional states and delirium is not fully understood, and the de nitions depend to some extent on their clinical causes and relationships, with all the imprecision that this entails The following nomenclature, though tentative, has proved useful to us and is employed in this and subsequent chapters throughout this book Confusion is a general term denoting the patient s incapacity to think with customary speed, clarity, and coherence Its most conspicuous attributes are impaired attention and power of concentration, disorientation which may be manifest or is demonstrated only by direct questioning, an inability to properly register immediate events and to recall them later, a diminution of all mental activity, including the normally constant inner ideation and sometimes by the appearance of bewilderment Thinking, speech, and the performance of goal-directed actions are impersistent or abruptly arrested by the intrusion of irrelevant thoughts or by the slightest external stimulus Reduced perceptiveness accompanied 355

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