Uremic delirium presents the usual features of toxic deliria: more or less complete clouding of consciousness, disorientation, phenomena of psychic automatism, among which psycho-sensory disorders occupy a prominent position.
The delusions, the emotional tone, and the reactions enable us to distinguish two principal forms of uraemic delirium: an expansive form and a depressed form.
The patient is a great personage, a general, a prince; he assists at a grand review, gives commands to his officers, or orders sixteen horses to be harnessed to his carriage; the Pope presents him with the imperial crown.
Often the delirium takes a mystic form: the heavens open, celestial music is heard, or angels descend on an immense ladder as in Jacob's dream.
Melancholy ideas combine with ideas of persecution and hallucinations of an unpleasant character. The patient imagines people are searching for him to drag him to the scaffold; the house is on fire; an odor of sulphur is diffused through the air.
Whatever the form of delirium, the reactions often rise to violent, at times terrible, agitation. Often, also, in the depressed and mystic forms, there is marked stupor with a tendency to cataleptoid attitudes.1
1 Brissaud. De la catatonie brightique. Sem. med., 1893. - Cullerre. Sur un cas de folie uremique consecutif a un retrecissement tranmalique de Vurethre. Arch, de neurol., Vol. XXVII, No. 89.
As to the development of the attack, we distinguish an acute form characterized by severe symptoms: intense agitation or, on the contrary, profound stupor, incessant hallucinations, extreme confusion with clouding of consciousness, etc.; and a subacute form characterized by symptoms of lesser intensity and by periods of comparative lucidity alternating with delirious periods.
In some exceptional cases of subacute form the delusions become systematized and may thus be misleading in the diagnosis.
The mental symptoms of ursemic delirium present no pathognomonic features and are merely a manifestation of poisoning of the cerebral cells. The diagnosis must be made from the accompanying somatic symptoms: convulsive attacks, cardiovascular disorders, dyspnoea, oedema, pupillary manifestations - myosis and paresis of the pupils - diminution of the specific gravity and of the toxicity of the urine, albuminuria, anuria, oliguria, or polyuria.
Ursemic delirium is often very similar to delirium tremens. It seems that the two affections may even be combined. Braultl is of the opinion that uraemia, like traumatism or pneumonia, may act as the exciting cause of an attack of delirium tremens. We have already seen how much importance is attributed by some authors, notably Herz, to uraemia as a pathogenic factor in delirium tremens.
The prognosis depends upon the severity of the somatic disturbances.
The treatment is that of uraemia in general: milk diet blood-letting, purgatives, and diaphoretics.
1 Traite de medecine. Charcot-Bouchard. Maladies des reins.