LECTURE XXIX.

ACUTE DELIRIUM (TYPHOMANIA). POST-FEBRILE INSANITY.

Historical References-The Term Typhomania-Definition -Ætiology—Emigration-Exposure to High Temperature-Physical, Mental, and Alco. holic Excesses-Symptoms-Develop Rapidly-Indications of FatigueInsomnia-Delirium, Character of-Subsides in about Two Weeks, and is Succeeded by Conditions of Semi-stupor-Countenance-Pupils— Tongue-Intolerance of Food and Drink-Pulse-Circulation-Vesicles -Examples-Morbid Anatomy-Diagnosis-Treatment-Post-febrile Insanity-General Remarks on the Delirium of Fevers-TrousseauDelirium in Children-Delirium in Typhoid Fever not of Serious Import -Three Forms of Mental Impairment Following Fever-Relative Importance of Each-Etiology-Unwise Treatment of Fevers in Reference to Feeding-Symptoms-May be of an Excited or Depressed TypePhysical Conditions are those of Anæmia and Perverted Nutrition-Dr. Hurd's Twenty-three Cases-Cases Following Surgical OperationsHochwart's Thirty-one Cases Following Eye Operations.-The Thirty-five Cases of the Retreat-Prognosis-Generally Favorable-Treatment.

ACUTE DELIRIUM.

Dr. Luther V. Bell first directed attention to and presented a paper upon this form of mental disease at the meeting of the Association of Superintendents of American Asylums, in 1849. He described it as a "New Form of Disease," which resembled some of the advanced stages of mania and fever, and yet so far differed from any described form of disease as to render it probable that it had hitherto been overlooked. In 1850 a paper was read before the

meeting of the same association by Dr. W. H. Ranney upon "Insane Foreigners," in which he alludes to this form of disease, as described by Dr. Bell, as one of frequent occurrence among emigrants, placing it second in point of frequency among those whom he had treated in the asylum on Blackwell's Island. He describes it as a "form of disease apparently intermediate between mania and typhoid fever," but gives it no definite name. In 1851, Dr. C. H. Nichols addressed a letter to the editor of the Journal of Insanity, enclosing a short communication from Dr. A. V. Williams to himself, in which he (Dr. Williams) gives some account of a form of insanity "which in our conversations and in my reports I have denominated typhomania, from the striking typhoid character of the physical symptoms it exhibits and the treatment required for its cure."

It thus appears that the term typhomania was not that of Dr. Bell, but Dr. Williams, and that it was used, at least in the earlier history of the disease, from the supposed relation it sustained to typhus or typhoid fever. To Dr. Bell, however, belongs the honor of first directing attention to it, differentiating and describing so fully its symptoms and march of progress that subsequent writers have added but little additional information in relation to them. This, however, could not be said in reference to its morbid anatomy, as the modern methods of examination of brain tissues were then unknown. While he suspected pathological changes in the brain from the character of the symptoms, he failed to satisfy himself that they existed, and Dr. J. B. F. Jackson was equally unable to demonstrate such morbid alterations of tissue. The investigations of later students have supplied this deficiency, and have more fully differentiated it from any form of or connection with typhus or typhoid fever.

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.

Etiology.-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 fright

ful 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 diarrhoea. 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.