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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
Hyperacute form (acute delirium). — This form is characterized by special intensity of the delirium and of the motor excitement on the one hand, and by great gravity of the general symptoms on the other hand.
The patient, attacked 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, the respiration is panting, the skin covered with perspiration, the 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: the appearance of mental confusion at the onset of the disease; the possibility of obtaining correct replies to simple and energetically put questions; the state of physical exhaustion, and the existence of the special etiological factors, which we shall mention further on.
Many psychoses may resemble primary mental confusion because they may be complicated by secondary mental confusion. The points of differential diagnosis have been indicated in the respective chapters devoted to the consideration of these psychoses.
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
1 Ballet et Faure. Contribution à l'anatomie pathologique de la psychose polynévritique et certaines formes de confusion mentale primitive. Presse méd., Nov. 30, 1898. Maurice Faure. Sur
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.
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.
les lésions cellulaires corticales observées dans six cas de troubles mentaux toxi-infectieux. Rev. neurol., Dec. 1899.
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 sitiophobia 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 artificial serum 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 Hayem's serum [or of normal saline solution] may be injected every day or every second day.
The most important results of this treatment are elevation of the 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 séreuse sous-cutanée dans les psychoses aiguës avec auto-intoxication. Prog. méd., Sept. 30, 1899. - Jacquin. Du sérum artificiel en Psychiatrie. Ann. méd. psych., May-June, 1900.
MISCELLANEOUS GROUPS (Continued).
CHRONIC INTOXICATION BY THE ALKALOIDS.
§ 1. MORPHINOMANIA.
CHRONIC intoxication by morphine brings about a condition known as morphinism. Morphinism constitutes morphinomania when the drug has become a necessity to the organism, so that its suppression causes a train of physical and psychical disturbances known as the symptoms of abstinence.
Etiology. The study of the etiology of morphinomania involves the consideration of two distinct questions: (1) What individuals are apt to become morphinomaniacs? (2) How does one become a morphinomaniac?
(1) What individuals are apt to become morphinomaniacs?
Morphine is no longer, as it was formerly, an aristocratic poison limited to the upper classes. "Even rural populations are no longer exempt from the contagion; and the fault is chiefly with the physicians." 1
Morphinomania is especially frequent among those who, on account of their profession or surroundings,
1 Chambard. Les morphinomanes. Bibliothèque médicale