"Collapse delirium" was first described by Hermann Weber in 1866. It takes the form of a stuporous state with confusion of thought, dreamy hallucinations, flight of ideas, an unstable emotional condition and an active motor excitement. The onset is usually sudden, following a period of sleeplessness and restlessness. Disorientation occurs early and consciousness is markedly clouded. Phantastic hallucinations and illusions are frequent. Excitement and confusion are also prominent symptoms. Flight of ideas is common and the patient often sings or expresses himself exclusively in verse or rhymes. Senseless and rapidly changing delusions are noted. The mood is elated, erotic, anxious or irritable, with outbursts of anger. Motor excitement is conspicuous and there is no sleep. Usually food is refused and nutrition disturbed with a great reduction of bodily weight. This condition is of short duration, usually not more than a few days, often terminating in sleep in favorable cases. Only a confused recollection of events remains on recovery. Collapse delirium, according to Kraepelin, is purely an infectious process and often occurs in pneumonia, erysipelas and influenza, following the subsidence of the active symptoms of the disease. It occasionally complicates articular rheumatism and scarlet fever. The characteristic features in erysipelas are hallucinations and delusions of a delirious type, while clouded states, confusional excitements and flight of ideas are more common after pneumonia. The symptoms usually develop after the temperature falls and other evidences of weakness are present. Kraepelin, however, recognizes infection as the only cause at this time, although he previously described these as exhaustive conditions.
Acute confusional states or amentia were described by Meynert in 1881. These are characterized by a clouding of consciousness with multiform manifestations of excitement both sensory and motor. Amentia is one of the sequelae of infectious diseases. It takes the form of a subacute development of a dreamlike confusion with hallucinations, illusions and motor excitement lasting usually for several months. It is very closely related to collapse delirium and the hallucinatory insanity of Hoche, Fürstner and others. The early symptoms are sleeplessness and unrest. The patients become anxious, forgetful, develop a fear of death, and cannot control their thoughts, complaining of dulness and confusion of mind. A difficult comprehension of external impressions develops. They may be attentive and seriously troubled at not being able properly to grasp their surroundings. A decided uncertainty and restlessness results. Everything seems changed or false. There is at first a feeling of inadequacy and a profound disturbance of thought which develops into a well defined confusional condition. A dreamlike state follows, sometimes with a tendency to fabrications. Rhymes, phrases and words may be repeated frequently. There is a tendency towards distractibility and flight of ideas with vague thoughts of persecution. Hallucinations sometimes become apparent, and illusions appear. The mood is usually one of irritable anxiety, suspicion and mistrust, seldom with complete dulness. Occasional outbursts of anger take place. A restless behavior is noted as a rule. Sometimes suicidal tendencies occur and mild stuporous states follow.
In another group of cases depression is an especially prominent feature as occasionally happens after typhoid fever; or states of excitement may exist with a flight of ideas and delusions of grandeur. Before the febrile disturbance has disappeared signs of restlessness are noted. Orientation is soon lost, apprehension is disturbed, the patient becomes distractible and begins to show hallucinations. Ideas of grandeur develop and fabrications are conspicuous and extravagant. The mood is angry and irritable, sometimes cheerful or elated, but very changeable. Restlessness, volubility, flight of ideas, senseless rhyming, confused writing and tendencies to sing, etc., soon appear. The sleep is very much disturbed. Very little nourishment is taken or it is refused entirely. Bodily weight is greatly reduced. The reflexes are usually increased, the pulse slow and the temperature subnormal. The duration of the disease is usually not more than from two to six months. Amentia usually follows typhoid, articular rheumatism, smallpox and cholera, and occasionally occurs after pneumonia. Symptoms invariably develop after the fever has subsided. After typhoid the characteristic features are excitement with hallucinations, delusions and variable moods; after articular rheumatism, disturbance of apprehension, restlessness, depression or even stupor; and after phthisis, hallucinations with preservation of consciousness and slight confusion.
Light forms of the infectious exhaustions, according to Kraepelin, may appear after convalescence from the more severe illnesses. The patient does not make a good recovery, is exhausted, cannot think clearly, tires easily and is not able to read or write letters. Mental activity is weakened and the patient remains in bed, apathetic and indifferent. Consciousness, orientation and perception are undisturbed, although hallucinations may appear when the eyes are closed or noises in the ears may be noticed. The mood is gloomy, hopeless, and sometimes irritable, with sudden attacks of anxiety at night. The patient becomes suspicious and has fears of death or poisoning. Hypochondriacal feelings with self-accusation may develop. Food may be refused and suicidal attempts occur. Some cases are reserved and quiet, even stuporous, expressing only a few delusional ideas at times. Sleep and appetite are affected and weight lost as a consequence. These lighter forms usually follow influenza, articular rheumatism, whooping cough, tuberculosis or chorea. The duration is ordinarily brief—a few weeks or months, followed by recovery. In some instances the disease may progress to a complete enfeeblement of the mental processes.
The exhaustive conditions in a large group of more severe cases are ushered in by a delirium or confusional state with a depressed mood. There is first a slight anxiety. Self-accusation and persecutory ideas appear early. Hallucinations of hearing and vision develop. The patients soon become clouded, inattentive, show difficulty of thought and loss of memory, with mental dulness. All grasp upon their surroundings is lost, they fail to recognize members of the family, and answer questions unintelligently. They have no appreciation of their condition and no memory for events. The mood is indifferent, apathetic or whining. It may be irritable, quarrelsome or violent. Usually they lie in bed and are entirely apathetic. Sometimes they show automatic movements and have to be fed. The conversation is often incoherent and meaningless. They are inclined to be emotional. Sleep is usually interfered with and they are restless at night. The appetite is lost. Occasionally evidences of brain lesions appear with paralyses, speech disturbance or epileptiform seizures. The duration is usually a matter of a number of months. At autopsy grave cell alterations and glia reactions are common. Rod cells are also found. Endothelial proliferation is frequently observed in the vessel walls. Some cases terminate in a chronic condition which may improve somewhat in time. There may be a persistent emotional and mental enfeeblement with indifference, loss of memory, lack of judgment and impairment of will. These "acute dementias" represent the terminal stages of cortical infectious processes. They have been observed after typhoid, rheumatism, erysipelas, cholera, smallpox and malaria. Usually after tubercular peritonitis or articular rheumatism there is a simple mental enfeeblement, while erysipelas is usually accompanied by mild excitements and an elated mood. The typhoid cases usually showed irritability, with outbursts of anger and confusional states with hallucinations and delusions. They occasionally terminate in more chronic conditions with permanent deterioration.
After typhoid, influenza and septic infections, Korsakow's "cerebropathica psychica toxaemica" sometimes occurs. This is the polyneuritic psychosis similar to that caused by alcohol. There is, however, a delirium or stupor at the same time.
The post-rheumatic psychoses have been studied exhaustively by Knauer.[266] Stuporous attacks were found in ninety-three per cent of his cases, following acute infections. He describes four groups showing psychotic manifestations:—
1. Anxious delirious excitements followed by stupor.
2. Excitements alternating with stupor.
3. Stuporous depression throughout.
4. Amentia-like excitements throughout.
The essential feature of Knauer's study was an analysis of post-rheumatic stupors. He describes these as clouded or dream states "not different from physiological sleep and the ordinary artificial narcoses." In them he sees a disturbance of apprehension, an interference with intellectual processes, a retention defect, and a loss of the power of attention. Catalepsy was found to be present in the majority of his cases. The loss of affect was described as being more complete than in manic-depressive psychoses. He speaks of the mood as sad, depressed, anxious, but above all, changeable.
Generally speaking this group of psychoses due to somatic disease is one which requires further study. We have comparatively little statistical information on the subject as yet. The differentiation of these conditions as outlined in the Association's statistical manual is as follows:—