Delirious Form

This form, much more frequent than the preceding one, owes its peculiar aspect to a more or less marked exaggeration of the activity of the mental automatism, which gives rise to: (a) flight of ideas and incoherence; (6) delusions and psycho-sensory disorders; (c) more or less motor excitement.

The delusions present no systematization, as for this at least a relative lucidity is necessary. They assume different forms, which often change; ideas of grandeur, transformation of personality, melancholy ideas, ideas of persecution. Painful delusions are the most common. Sometimes the ideas are absurd, like those of senile dements or of general paralytics.

The psycho-sensory disorders consist sometimes in agreeable, but more often in painful, illusions and hallucinations of all the senses, though most often of vision and of hearing. They may combine so as to create an imaginary world which is mobile and changeable, or, on the contrary, they may exist together without any apparent correlation.

Occasionally the incessant illusions and hallucinations impart to the patient a peculiar expression. Most cases described under the name of hallucinatory delirium should properly be included in this form of mental confusion.

The emotional tone is variable, governed to some extent by the delusions. However, one often finds, in spite of very active delirium, a striking indifference, so that a certain discord exists between the delusions and the emotions.

The motor excitement is not always due to delusions or psycho-sensory disturbances. As in dementia praeccx, so also in this condition the patient may give vent to cries and motor discharges that are purely automatic and without any apparent purpose.

Stuporous Form

Here the psychic paralysis involves not only the higher mental faculties, but also the automatic functions.

The limbs are motionless, the eyes dull, and the face expressionless; the mouth may be half open and the saliva dribbling away uncontrolled. The patient fails to react even to the strongest stimulation, or he may react but very feebly.

Cataleptic attitudes with dilated pupils are frequently seen.

Hyperacute Form (Acute Delirium)

This form is characterized by special intensity of the delirium and motor excitement, and by great gravity of the general symptoms.

The patient, assailed by numerous hallucinations, either painful, or agreeable and accompanied by erotic tendencies, becomes completely disoriented and wildly excited: he shouts, sings, jumps out of bed, strikes the walls, and attacks those about him. The eyes are injected, respiration is panting, skin covered with perspiration, temperature high, and the pulse small and often rapid and irregular. These signs point to the general gravity of the condition. In fatal cases the patient rapidly passes into coma and dies in a few days. In favorable cases the agitation gradually disappears, the patient regains his sleep, and recovery finally takes place; this favorable termination is rare.

Duration, Course, and Prognosis of Primary Mental Confusion

The duration of the attack varies from several days to a few months. The curve representing its intensity is rapidly ascendant, then it remains stationary for some time with some oscillations, and finally descends gradually. The period of descent often presents irregularities on account of recrudescences of the disease, which are usually mild.

Such is the course of favorable cases, which fortunately are the most frequent (excluding acute delirium). Recovery is complete. But the patient's recollection of the events which have taken place during his illness is vague or even absent. The period of convalescence is protracted.

Suicide is rare even in the depressed forms; the aboulia is the patient's safeguard.

In unfavorable cases death occurs from collapse in the hyperacute form, and from cachexia or from some complication (pneumonia, subacute tuberculosis, influenza, infections following traumatisms) in the less rapid cases.

Diagnosis

The principal elements of diagnosis are: appearance of mental confusion at the onset; possibility of obtaining correct replies to simple and energetically put questions; state of physical exhaustion, and existence of the special etiological factors, which we shall mention farther on.

Pathological Anatomy

The lesions of primary mental confusion are of two kinds: inflammatory and degenerative. The former, which are most prominent in the severe cases, consist in congestion and diapedesis in the nervous centers. The latter are more constant, and consist in degeneration of the nerve-cells, which is demonstrable by Nissl's method.1

Etiology

All factors capable of bringing about rapid and profound exhaustion of the organism occur in the etiology of primary mental confusion: physical and mental stress, painful and prolonged emotions, but especially grave somatic affections. The puerperal state, through the exhaustion which it entails as well as through the nutritive disorders and infections by which it is sometimes complicated; the infectious diseases (typhoid fever, the eruptive fevers, influenza, cholera); profuse hemorrhages; inanition, etc., are among the causes frequently found in the history of the disease.

How is the action of these factors to be explained? Two hypotheses are possible.

According to one, that of Binswanger, the general exhaustion of the organism brings about deficient cerebral nutrition the clinical expression of which is primary mental confusion.

1 Ballet et Faure. Contribution a l'anatomie pathologique de la psychose polynevritique et certaines formes de confusion mentale primitive. Presse med, Nov., 30, 1898. - Maurice Faure. Sur les lesions cellu-laires corticales observees dans six cas de troubles mentaux toxi-infectieux. Rev. neurol., Dec, 1899.

According to the other, advanced by Kraepelin, the causes enumerated above bring about disturbances in the nutritive changes and determine the production of toxic substances which, acting upon the cerebral cells, give rise to an intoxication psychosis: primary mental confusion.

Perhaps both causes are at work simultaneously. In either case exhaustion constitutes the essential cause of the affection and the term "Exhaustion Psychosis" is therefore perfectly applicable to it.

Treatment

During the entire acute period of the disease rest in bed should be rigorously enforced.

Proper alimentation is of great importance. A reconstructive diet better than all medication sustains the patient's strength and even calms the agitation. Milk, eggs, chopped meat, and meat-juice should form the basis of the diet.

In cases of refusal of food one must resort without hesitation to artificial feeding; these patients cannot with impunity be allowed to fast. Gastric lavage sometimes gives good results, even in cases of acute delirium.

. Injections of saline solution are of great service and easy of application. The necessary apparatus consists chiefly of a glass funnel, a soft-rubber tube, and a slender trochar.

Ordinarily 300-500 grams of normal saline solution may be injected every day or every second day.

The most important results of this treatment are elevation of blood pressure and diuresis.1

Moderate physical exercise, life in the open air, reading, and light mental work for brief periods at a time accelerate the course of convalescence.

1 Cullerre. De la transfusion sereuse sous-cutanie dans les psychoses aigues avec auto-intoxication. Presse med., Sept. 30, 1899. - Jacquin. Du serum artificial en Psychiatric Ann. med. psych., May-June, 1900.