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Definition.-Acute delirium is an affection accompanied with great mental disorder, a rapid development and course, more often than otherwise fatal, and presenting symptoms which resemble in a marked degree those attending certain very acute cases of typhus, typhoid, and puerperal fevers, meningitis, and some degree of intoxication.

It is more common among females than males.

Ætiology.-Dr. Ranney was of the opinion that the disease was caused more often among immigrants from the unfavorable condition attending the passage to this country and the disappointments arising during the earlier periods after arriving, such as the crowded and poorly ventilated rooms occupied on the steamers and failure to secure employment, and consequent worry and anxiety. Heredity, predisposition to brain disorder, excessive heat, great physical, mental, and alcoholic excesses, are all believed to hold an important relation as causes.

Symptoms.-Psychical.—The mental symptoms develop much more rapidly than is usually the case in either mania or melancholia. Frequently there exists some such history as that patients have not been quite well, have complained of or have given indications of fatigue, lassitude, and an indisposition to pursue usual avocations; have been restless, nervous, and unusually irritable, but not enough so to lead to the apprehension of friends or themselves. After a short time, perhaps a few days, pain in the head becomes pronounced, the patient is unable to sleep, and the mind passes quite suddenly into a state of acute delirium, which is generally attended by indistinct hallucinations of sight. These are not infrequently of a frightful character, such as burning buildings, or flames in the room, and of blood upon the walls or ceiling, and every effort will be made to escape from the dangers and frightful sight. At other times the hallucinations refer to some person supposed to be an enemy who is in pursuit of them for the purpose of throwing them from a precipice or into the flames, and the patient struggles with desperation to escape, until he falls back bathed in perspiration and quite exhausted. Hallucinations of hearing are much less frequent than those of sight, and definite delusions do not appear to exist unless those of fear. When apparently free from hallucinations and lying upon a bed, the hands are often in constant motion, striking each other or at the attendant, or the patient is counting off some special number on the fingers, or making some childish rhyme, such as one, two, three, don't you see, or two, three, four, open the door, etc., etc., and then the mind recurs at once to the phantom panorama, which seems to be ever floating past the mental vision with the greatest rapidity and evanescent nature. The flow of words addressed to this vision is constant, and constantly changes without sequence, coherence, or order. In fact, it appears to be almost or quite automatic.

One of the most constant symptoms during the earlier stages of the disease is inability to sleep, and large doses of the ordinary soporific medicines have very little effect. In the case of females there exists not infrequently a fear, or phantom delusion, that they have been foully dealt with and are about to be in labor. In the midst of these delirous mutterings, however, it is quite possible to gain the attention for a moment, and the tongue will be protruded and an answer given to a question. The patient may recognize the physician or attendant, calling them by name, and then at once resume the iteration of an endless medley of words or sentences, roll the head upon the pillow, and the agitation and restlessness become extremely excessive, the patient rolling about the floor or rushing about the room unless restrained.

This general condition of restless delirium continues during ten days or two weeks, and then gradually subsides. The flow of words ceases, sometimes from inability to articulate, and at others apparently from a fading out or a diminution of the vividness of the hallucinations of sight. The mental function appears to be quite in abeyance, and the patient lies unconscious, sleeping several hours a day, and never able to comprehend, and much less to answer, any questions.

2d, Physical. At this period the physical symptoms have become quite fully pronounced, having steadily developed since the third or fourth day. The face is pinched, anxious, and frequently of a dark, dusky hue, especially under the eyes, and the general expression is one of fear. The pupils may be either contracted or dilated, but are not tolerant of light, while the vessels of the conjunctivæ are often injected. The hands and tongue are tremulous, while the latter is brown, and the teeth covered with dark sordes; the lips become dry and cracked, and the throat full of a thick, tenacious mucus, so that the patient is unable to swallow even fluids without great difficulty. The stomach is intolerant of food and drink, and what is given is soon vomited. The pulse is not much above 100 except in fatal cases and toward the end; during the early stages it may be below normal, while the extremities are cold and require artificial warmth. In the earlier stages the bowels are constipated, but later there may be diarrhæa. The action of the heart is generally feeble, and in nearly all cases the capillary circulation is much impeded in consequence of the paralysis of the vaso-motor nerves, so that the slightest bruises become inflamed or ulcerated.

In a certain proportion of cases, more particularly during the later stages of such as prove fatal, small vesicles appear upon certain portions of the body and limbs; a thin, whitish fluid exudes under the cuticle, which soon breaks and a dark brown scab is formed, which becomes from one-fourth to one-half of an inch in diameter and one-sixteenth or two-sixteenths of an inch in thickness. These are quite irregularly scattered about the anterior surface of the body and limbs, but I have never observed either sudamina or petechiæ.

Generally there occurs a crisis within two weeks. The delirium ceases and a dawning of consciousness returns. The stomach becomes more tolerant of food, the pulse less frequent, and the temperature normal. The interval which has passed is a mental blank, and with surprise patients inquire where they are. The cessation of the delirium is rarely followed by dementia or delusions, and when it is so, according to Dr. Ranney, it is only in cases which have had previous attacks of insanity. The recovery is usually quite rapid.

While the above enumeration of symptoms is fairly accurate in typical cases of acute delirium, yet it should be stated that cases are sometimes seen in which these symptoms appear only in a modified form. They have the essential characteristics but do not pass over into their fully developed character, and may not do so if patients are properly treated from the first, and are otherwise favorably conditioned.

Example 1.—Miss A. R., age thirty-two; admitted September 23, 1887; parents not living; has been a teacher during the past thirteen years. She was a fine scholarstanding the first in her class at graduation-and has risen to a high position as teacher. During the previous summer vacation she had been in the country, but much engaged in planning the organization of a department of physics, of which she was to have charge the next year. Her sisters report that she did not appear quite as well as usual when she left the country for the city to resume the duties of the school, but little or nothing was thought of this. She entered at once upon duty at the opening of the school, and five days afterward felt “ so nervous” that she consulted her physician and did not hear her classes; that same night she became delirious, and remained without sleep during seventy-two hours, when she was brought to the Retreat, with the report that notwithstanding the administration of three grains of morphine, with doses of chloral and bromide, during the previous night she had not slept and it required four persons to control her.

At the time of admission the pulse was 100 per minute, quite weak, but there was no rise in the temperature. The tongue was covered with a whitish coat and dry. She was constantly talking, repeating meaningless, rambling sentences or words, and addressing persons whom she seemed to see passing. The movements of hands and feet were constant, and she rolled from side to side, and would have gone to the floor if permitted. She was given hypodermically one-hundredth of a grain of hyoscine, but no chloral or morphine. The next night she slept one and one-half hours, and about the same on the third and fourth nights. There was no sleep on the fifth night, but from this time forward there were two or more hours of sleep every night. After one or two days the tongue became brown, the lips dry and cracked, and the teeth covered with dark sordes, the bowels were constipated, the throat filled with thick, tenacious mucus, and she was unable to swallow. On the fifth night

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