familiar to him, although this power is only gradually lost, and after conscious efforts made to retain a coherence, and then the mutterings become louder, the listless inaction becomes endless activity, and the tongue is incessantly employed in uttering incoherent nonsense. Most diseases which have a fatal termination at some period of their course present symptoms of some disturbance of the mental functions, and many of them are accompanied, especially towards their termination, by the symptoms which we have to consider in this chapter. Thus, delirium arises in connection with organic diseases of the brain -for example, inflammation of its membranes,* or it may arise in the course or during the decline of such acute diseases as pneumonia, measles, or fever. It not unfrequently comes in connection with phthisis, acute rheumatism, or epilepsy. It may be induced by excessive fatigue, long continuance in the use of intoxicating liquors, or by the conditions which accompany parturition. It is also to be remembered that delirium is a symptom of poisoning by belladonna, henbane, and stramonium, that it frequently results from poisoning by other poisons which are classed under the head narcotico acrids, that it occasionally arises from overdoses of the pure narcotics, and may be brought on even by the action of some of the irritant poisons. When delirium does occur as a concomitant of inflammation of the mucous or serous membranes of the liver, spleen, or kidneys, it only appears when the disease is approaching a fatal termination; and the same observation is true of the delirium which sometimes supervenes upon a surgical operation.

With regard to the symptoms of this disease, when it does give warning of its approach it does so by means of flushing of the face, pain and throbbing in the head, and heat of the scalp. After the mental symptoms mentioned above have shown themselves, while the patient is labouring under the incoherence described and is unable to be aroused to any attentive effort, the eyes are generally open, dry, and bloodshot, and "staring so blindly!" The skin is generally dry, hot, and the patient is restless, and is inclined to indulge in continuous activity of some sort, which is occasionally rhythmic. Even his loud talk, his cries or exclamations, his uneasy tossings, have often a rhythmic character. The patient at this stage of the disease is generally very restless, and is with difficulty kept in bed. With regard to the peculiarity of the thoughts of * See Reynolds' System of Medicine,' pp. 358, 417, 683.

those who are labouring under maniacal delirium it has been remarked that very often dead memories are brought to life again.

"One sees the dungeons of a head

When fever opens all the doors."

Thus, the case given by Coleridge in his 'Biographia Literaria,'* which is so often quoted in philosophical discussions, is one in point. It is that of a young girl who, while labouring under nervous fever, was found in her incoherence to be quoting Latin, Greek, and Hebrew, "in very pompous tones, and with most distinct enunciation." The explanation of this very curious phenomenon was simple. When the girl, who was in very poor circumstances, was only nine years old she had been charitably taken by an old Protestant pastor, and had remained with him until his death. It was ascertained that this pastor had been a very learned man and a great Hebraist; and amongst his books were found a collection of Rabbinical writings, together with several of the Latin and Greek fathers, and there was no difficulty in identifying many of the passages which the servant girl had quoted in her delirium. It was proved that all these passages had become a part of her memory by means of unconscious eavesdropping, for the pastor used to read aloud, and the girl must have heard him while she was at work in the kitchen.

Another somewhat similar case illustrating the curious resurrection of dead memories in dreams and delirium will be found in Lord Monboddo's Ancient Metaphysics.'* Where the disease, of which the delirium is a symptom is about to prove fatal, the incoherence and restlessness disappear, and are generally succeeded by coma, but occasionally just before death the mind becomes clear although enfeebled by disease. In this state the individual is quite capable of recognising his relations, can speak rationally, is cognizant of what is going on around him, and may often be in a position to do certain legal acts with all the mental capacity which is required by law. As this state may sometimes continue for some hours, and even in rare cases for days before death, its recognition by medical jurists is of the utmost importance. The distinction then to which we adverted, which exists between acute mania and

* Vol. i, p. 117 (ed. 1847).

† Vol. ii, p. 217. See also Rush on 'Disease of Mind,' p. 282.

acute maniacal delirium is one which it will not do to overlook. As a question of treatment difficulty will arise unless the distinction is clearly appreciated. In the one case it would be proper to suggest exercise and open air, and these should be procured even if a certain amount of restraint was necessary for the purpose; in the other such treatment would be most unscientific, and would accelerate the fatal issue of the disease. Again, with regard to the removal of the sufferer to an asylum the diagnosis is of paramount importance, for there are many patients who, if treated at home by friends, might probably recover, would by removal to an asylum be placed in much less favorable circumstances, and that, when no such removal was necessary, as for the short time which delirium lasts, all the necessary comforts and conveniences could be supplied at the patient's own residence. A mention of the points in which mania differs from delirium may be of some use.*

In mania the patient is capable of recognising persons and things, and is alive to the circumstances which occur in his presence. In delirium the patient is generally unable to make any distinctions, memories are confounded with perceptions, and are often more real than sensual impressions. It follows that in delirium there is an entire absence of the power of reasoning which is a faculty of relations, and where comparison is impossible there also ratiocination is unattainable. In delirium there is a chaos of ideas, not one stone of the mental house has been left upon another; the individual is sane in nothing; ideas have lost all the molecularity which gives them coherence.

In mania, however, this is not the case. The individual does reason; the laws of association have been tampered with, but they still exist. The individual can at times be coherent and rational. He retains command over his muscles, will occasionally understand and laugh at a joke, can occasionally follow for a short time the windings of a conversation, and can often be made to see the ridiculous character of his conduct. His senses are acute, the bodily functions are undisturbed. The health is not materially impaired, and the presence of mania is not a cause for the apprehension of immediate death, although it does shorten life.

In

* Two cases are described by Dr. Maudsley in the Journal of Mental Sci. (vol. xiii, p. 59), which illustrate some of the distinguishing features of these two conditions.

delirium, on the other hand, there is muscular prostration, sensation is impaired, every bodily function is more or less interfered with, and the disease with which it is associated is speedily terminated by death or by restoration to complete health. As delirium is, as it were, a parasite upon another disease, its life is determined by that of the disease of which it is the concomitant; when that is aggravated it is increased; when that is removed it ceases to exist. One other feature has been remarked with regard to this morbid condition which is not unworthy of notice, and that is, that while mania never occurs until after the age of puberty delirium has, like death, "all seasons for its own.'

* See with regard to delirium Georget in 'Dict. de Médecine,' t. vi, p. 395; Esquirol in 'Dict. des Scien. Med.,' t. viii, art. " Délire.”

CHAPTER XVII.

ON THE LEGAL RELATIONS OF MANIACAL DELIRIUM.

In relation to delirium there can be no question as to the existence of lucid intervals. Sir John Nicholl has said, "in cases of permanent, proper insanity the proof of a lucid interval is matter of extreme difficulty, and for this among other reasons, namely, that the patient so affected is not unfrequently rational to all outward appearance without any real abatement of his malady; so that, in truth and substance, he is just as insane in his apparently rational as he is in his visible raving fits. But the apparently rational intervals of persons merely delirious, for the most part, are really such. Delirium is a fluctuating state of mind created by temporary excitement, in the absence of which, to be ascertained by the appearance of the patient, the patient is most commonly really sane. Hence, as also, indeed, from their greater presumed frequency in most instances in cases of delirium, the probabilities a priori in favour of a lucid interval are infinitely stronger in a case of delirium than in one of permanent, proper insanity, and the difficulty of proving a lucid interval is less in the same exact proportion in the former than it is in the latter case, and has always been so held by this court."*

When, then, lucid intervals can be proved to exist in the course of delirium, it would be very unjust to deprive individuals who may be thus affected of exercising those privileges which during health they have a right to enjoy. Thus testamentary dispositions made during the intervals of febrile delirium ought, if the lucidity of the interval can be proved, to be upheld. It is not, by any means, uncommon to find that wills made under such circumstances

are

*Brogden v. Brown, 2 Addams 441. See also Evans v. Knight, 1 Ad. 229, and Lemann v. Bonsall, 1 Ad. 383.