Clouding of consciousness is here permanent. The attack begins suddenly or after a short prodromal period, characterized from the beginning by complete disorientation, very great excitement, and totally incoherent delusions. Numerous hallucinations always accompany the delusions. The form of the delusions is very variable: in confused mania are often encountered ideas of grandeur, persecution, and occasionally, by way of an accidental episode, some melancholy delusions.
Even when the grandiose ideas predominate euphoria is very frequently absent. The cause of this anomaly probably exists in the purely automatic character of all the psychic manifestations. To provoke a sense of pleasure activity must be conscious, that is to say, accompanied by a voluntary effort, no matter how slight; whereas in confused mania fragmentation of the personality is such that flight of ideas is effected with extreme facility: effort is absent and with it the euphoria.
The patient loses weight, the features become drawn jut, the pulse grows small and depressible. The intensity of the excitement permits of no regular alimentation.
Filthy tendencies are frequent: unless watched constantly the patient is apt to smear the walls, his bed, his clothing, and his body with faeces. Some will even eat faeces.
The attack may terminate in death, either from exhaustion or from some complication: pneumonia, suppuration occasioned by traumatism, etc.