DELIRIUM. 
BY 
W. L. WORCESTER, M. D., 
Little Rock, Arkansas. 
FROM 
American .Journal ot Ensamtn, 
July, 1889. 
UTICA, N. Y. DELIRIUM. 
BY W. L. WORCESTER, M. D., 
Assistant Physician, Arkansas State Lunatic Asylum, Little Rock. 
Delirium is a subject the knowledge of which seems to be taken 
for granted by most writers, whether on general medicine or 
nervous diseases. Its occurrence is mentioned in connection with 
the various diseases with which it is associated, but there is, so far 
as I have noticed, in my reading, little effort to give an accurate 
description of the condition, or to differentiate it from other forms 
of mental derangement, except as regards its etiology. When any 
attempt is made to detine it, the writer generally contents himself 
with saying, more or less elaborately, that it is the same thing as 
insanity, except that in the former case, the disease of which the 
mental disturbance is symptomatic is known, and in the latter is 
unknown. Gowers, for instance (Diseases of the Nervous System, 
p. 530), after mentioning the presence of delusions, hallucinations 
and illusions, says : “ The condition of delirium is essentially the 
same as that w’hich constitutes insanity, but the term ‘ delirium’ is 
usually confined to the acute mental derangement that occurs as a 
consequence of organic brain disease, of pyrexia, of toxaemic con- 
ditions or of inanition. In these conditions the disease of which it 
is a symptom is also recognizable. The similar mental condition 
which occurs apart from these conditions, and which constitutes 
the sole evidence of disease is regarded as ‘insanity.’” After 
making the distinction between quiet and active delirium, he goes 
on to say: “Although the general elements of delirium are iden- 
tical with those of the mental derangement termed insanity, yet 
certain common features of insanity are rarely seen in delirium. 
Such are the emotional depression of melancholia, the exaggera- 
tion of idea which characterizes some cases of general paralysis 
of the insane, the outrageous delusions of personal identity met 
with in the latter, and in some cases of chronic insanity; and, 
lastly, the rhetorical loquacity of acute mania is, to say the least, 
extremely rare in symptomatic delirium.” 
It is hardly proper to speak of “the mental derangement which 
constitutes insanity,” as if there were but one. A great many 
different mental derangements occur in insanity, a number of which, 
it will be noticed, the writer goes on to mention. Neither is it 2 
correct to say that the mental condition “ constitutes the sole evi- 
dence of disease ” in all forms of insanity. This is very far from 
being the case in general paralysis—the delusions of which he 
expressly differentiates from delirium, in epilepsy, and in acute 
delirium, to mention no othei’S. 
It is probably true that, so far as symptomatic delirium is con- 
cerned, an accurate definition is not of the first importance. Even 
the beginner in medical practice, meeting with evidence of dis- 
ordered mental action in a case of typhoid fevei- or pneumonia' 
would be likely to guess that he had to do with delirium. Still, it 
may not be amiss to inquire what mental derangements are char- 
acteristic of symptomatic delirium, and under what conditions 
similar disturbances occur in what is ordinarily recognized as 
“ insanity.” 
The symptoms can be most satisfactorily studied in cases in 
which the intellectual disorder comes on gradually. In such cases 
hallucinations or illusions of sight are apt to be the first thing 
noticed. Their character is often appreciated by the patient, who 
may take an interest in observing them, and discuss them with the 
persons about him. As the delirium progresses, he loses his sense 
of the nature of sensory disturbances, and ceases to appi’eciate his 
surroundings. Very often, however, he can be momentarily 
recalled to consciousness, and will then realize where he is, and 
answer questions correctly, but immediately relapse into his former 
condition. Later, the hallucinations, illusions and delusions may 
dominate the consciousness completely; the patient loses all sense- 
of where he is, and fails to recognize his most intimate friends. 
He may lie quietly, paying no attention to what goes on about 
him, and muttering incoherently to himself, or, if his impressions 
are ot a vivid chai’actei*, may attempt to go away about his busi- 
ness, or assault those who are with him, under the idea that they 
are enemies, or leap out of the window to escape imaginary foes. 
The emotional tone depends upon the nature of the delusions and 
hallucinations; it may be cheerful or even hilarious, or anxious and 
troubled, even to the wildest terror and despair. In case of 
recovery, the recollection of what passed through the mind is apt 
to be impei'fect and confused, and the time may be a complete 
blank to the memory. Sometimes, however, the impressions are so 
vivid that it is difficult for the person who has felt them to realize 
that they were not actual occurrences. 
In all these points the l’esemblance to the phenomena of dreams 
is very strong, and is doubtless more than a superficial one. In 3 
sleep the higher faculties of the mind, reason and judgment are in 
abeyance; we are unable to compare fancies with facts, and to 
correct the ideas suggested by one sense by another. Tn fever the 
same results are brought about by the malnutrition of the brain. 
From the fact, however, that hallucinations often occur in delirium 
when the patient is able to appreciate their nature, it is evident 
that in addition to the enfeeblement of the judgment there is an 
unnatural activity of the portions of the brain concerned in the 
reception of sensory impressions. From the fact, occasionally 
noticed, that the hallucinations of dreams sometimes persist for a 
few moments after waking, it is probable that the same thing is 
true in dreaming. 
What should be considered the essential and uniform features 
of delirium, and what its accidental symptoms ? So far as my 
own observation extends, and so far as I have been able to learn 
from the statements of others, there are two classes of symptoms 
which are invariably present singly, or, more usually, in combination, 
in febrile delirium, namely, sensory disturbances—illusions and. 
hallucinations—and mental bewilderment, with failure to rightly 
recognize surrounding persons and objects. The emotional con- 
dition may be pleasurable or painful; there may or may not be 
motor restlessness; there may or may not be delusions properly so 
called. 
The same essential features are found in delirium from inanition, 
from poisons, and, very commonly, in the death agony. The char- 
acter of the hallucinations often varies with the nature of the 
exciting cause. In delirium tremens they are too well known to 
require description; in intoxication from Indian hemp, there is 
exaggeration of the sense of space and time; in intoxication from 
the inhalation of ether, chloroform, nitrous oxide and the like, the 
character of the delirium is apt to be affected by the ideas which were 
uppermost in the patient’s mind when he came under their influence. 
In starvation the sufferer revels in imaginary feasts ; the dying 
man is apt to live over the scenes of his past life. In all, the 
patient dwells in a more or less completely imaginary world. 
If the foregoing is a correct statement of the facts, delirium 
would seem to be a pretty well-defined mental condition, with 
characteristic symptoms. Let us now consider under what circum- 
stances the same combination of symptoms is found in those forms 
of mental derangement commonly known as “insanity.” 
I.—Mania. In mania the characteristic symptom seems to me to 
be the weakening or loss of the inhibitory activities of the mind. 4 
The patient is like a clock from which the pendulum weight has 
been removed; there is a rapid, unregulated discharge of nervous 
force through the most diverse channels. The restlessness, the 
loquacity, the impulses to violence and destruction, the loss of 
sense of propriety are all allied phenomena, and are alike due to 
the loss of control which our higher faculties exercise, normally, 
over the lower activities. 
Although mania is, I think, the form of insanity which is com- 
monly thought to have most in common with delirium, it is evi- 
dent that in many cases there is little resemblance between 
the two conditions. Certainly no one would think of com- 
paring the typhoid patient, lying with half-closed eyes, 
picking at the bedclothes, muttering incoherently and entirely 
oblivious of his surroundings, with such a case of mania 
as we often see, with every muscle tense and every 
sense on the alert, abounding in witty retort, or pouring out a 
torrent of apposite vituperation; yet the one is thoroughly 
delirious and the other thoroughly maniacal. In other words, we 
may have delirium without the restlessness characteristic of mania; 
and mania, even of a very high degree, without the sensory dis- 
turbances and mental confusion of delirium. 
In a considerable proportion of cases of mania, however, 
hallucinations and failure to comprehend surroundings are 
present. Although, as a rule, theye are cases in which there 
is a very considerable degree of excitement, still there is 
no uniform relation between the severity of the maniacal 
symptoms strictly speaking, and the degree of sensory dis- 
turbance and mental confusion, and it seems to me that 
delirium should be considered a complication rather than 
an intensification of mania. From my recollection of the 
patients who came under my observation at the Michigan Asylum 
for the Insane, it is my decided impression, though I am not now 
able to furnish statistical proof of it, that these symptoms are 
much less common in cases of recurrent or paroxysmal mania than 
in those in which the patients either recover permanently or pass 
into terminal dementia after a single attack. If the experience of 
others should confirm this impression, the existence of hallucina- 
tions and mental confusion would have some degree of diagnostic 
and prognostic significance. 
II.—Melancholia. Although delusions are much more generally 
present in melancholia than in mania, hallucinations and mental 
confusion are far less frequent. Even in the cases in which the 5 
patients seem, on superficial observation to have hallucinations of 
hearing, in the form of commands to kill themselves, to abstain 
from food, and the like, careful inquiry will usually make it appear 
that the voice seems to them an inward rather than outward one. 
In the raptus melancholicus, however, hallucinations seem to be 
very generally present, and there is a state of mental bewilderment 
very similar to what is seen in febrile delirium of a distressing 
nature. 
III. —Acute Delirium—Delirium Grave—Acute Delirious Alania. 
It is not neccessary, for the purposes of this paper, to enter into 
any extended discussion of this disease. The analogy of the 
mental symptoms with those of delirium from other causes has 
impressed - all who have recognized it as a distinct disease, and 
governed its nomenclature. The symptoms characteristic of 
delirium, hallucinations and illusions with mental bewilderment are 
here present in the highest degrfee. 
IV. —Epilepsy. In the so-called psychical equivalent for 
convulsions, which, however, so far as my observation goes, are 
more frequently states of impaired consciousness following slight 
convulsions, and in epileptic frenzy, appreciation of surroundings 
is greatly impaired, and there is often evidence of hallucinations. 
This is the case in the “ dreamy states ” described by Jackson 
(1 Brain, Vol. Ill, p. 199). The analogy of these conditions with, 
those already described seems to me evident. 
V. —Katatonia and Stuporous Disanity. Whether the combina- 
tion of symptoms described by Kahlbaum under the title of 
“ Katatonia ” should be considered distinct from other cases in 
which there is a cataleptoid condition without the active disturb- 
ances considered characteristic of that form of disease, I will not 
now discuss. In both states the conduct of the patients often 
gives evidence of hallucinations, and uniformly of a failure rightly 
to appreciate their environment, which, in my experience, is in- 
variably confirmed by the statements of such patients as are able 
to give an account of their experience during the attack. The 
violent and impulsive outbreaks which often occur appear to be 
due to, or at least accompanied by hallucinations, usually of a 
terrifying character. In the lethargic condition the mental state 
seems analogous to nightmare. 
General Paresis. In this disease there not infrequently occurs 
a condition of violent, aimless excitement, in which the patient is 6 
in a state of complete bewilderment. He does not realize where 
he is, nor recognize the persons around him; his ideas of what he 
would accomplish are of the most vague and indefinite character, 
and he has no judgment in regard to the means of putting them 
into effect. It is probable that hallucinations are usually present 
in this condition, but they are seldom conspicuous. 
The above are the principal forms of insanity in which I have 
observed symptoms such as are commonly understood when a 
patient is spoken of as “ delirious.” The term has, however, often 
been applied to conditions which seem to me dissimilar to maniacal 
excitement without mental confusion or sensory disturbance, and 
more especially to delusional states. Inasmuch as, when the term 
is used without qualification, it is applied to a pretty well-defined 
and constant group of symptoms, it seems to me that there would 
be a gain in clearness if, on the one hand, those cases in which 
these symptoms—hallucinations with bewilderment as to surround- 
ings—were classed together as delirious, and, on the other hand, 
the term were limited to them. Apart from the fact that all are 
morbid mental states, delirium as above described is hardly more 
like the systematized delusions of paranoia, or the simple mental 
enfeeblement of many cases of dementia than it is like mental san- 
ity. The term is a convenient one to characterize a pretty well- 
defined group of symptoms. When extended to cover the whole 
field of mental derangement, it is superfluous, if not misleading.