especially where the patients consist of the lower orders, who are unaccustomed to personal cleanliness. Esquirol may well complain of it in La Salpetrière; for the inmates, according to his own report, are much affected by scurvy, a disease in which the gums of course are spongy and putrescent.

The dejections of maniacs have commonly a very offensive, but not peculiar smell. Neither is it always the effect of vitiated biliary secretions, or unconcocted ingesta; for strong mental impressions often occasion singular changes in all the excretions.

COMMENTARY III.

DELIRIUM.

DELIRIUM and mania or insanity are commonly confounded and considered to be the same. But the delirium of acute and sympathetic diseases is different from that delirium or disturbance of the intellectual faculties which characterises insanity. It is true that derangement of those faculties is essential to constitute insanity, and that there can be no insanity without delirium. But delirium may be established quite independent of that peculiar action of the cerebral organs which is the maniacal. This distinction is very important to be observed; for as different affections, derived from different states of the brain, they require opposite modes of treatment.

That they are confounded, notwithstanding the diagnosis of each has been particularly marked by writers of authority, must, I think, be imputed in a great degree to the vagueness of the word delirium. It is to be regretted, that our vernacular tongue does not furnish any word which contradistinguishes the two morbid conditions of the understanding which fever and other acute disorders and insanity present.

Aretæus recognises a distinct difference between phre-` nitic and maniacal delirium. He conceived that in the former the sensorium was affected, for things not present appear to be so; in the latter, objects are seen in their proper light, but the conception of them is erroneous.*

* Morb. Diuturn. lib. i. cap. vi.

Hoffman appears to have been aware of the difficulty in discriminating, and therefore affixes the adjunct, maniacum, to designate the delirium peculiar to mental derangement. His example may be very inconvenient to follow, since delirium is the accompaniment of so great a variety of diseases and affections; but there is no other method when we wish to mark the difference.

Cullen expressly recognises a difference between maniacal and other deliria ;* and had the distinction which he makes been duly regarded, the mistakes in the diagnosis of diseases attended by mental disturbance, would more generally be avoided.

Nosologists have added, perhaps, to the misconception of the real character of delirium, on account of the various ranks which they have assigned to it in their respective systems.

Sauvages and Sagar class delirium as the third order of vesaniæ, and make mania and melancholia distinct genera. Linnæus and Vogel rank delirium, mania, and melancholia, all as genera. Sennert, Boerhaave, &c. consider delirium in reference only to mental aberration, and examine it as a phenomenon independent on febrile action. Burserius gives it the importance of a genus; and so likewise does Crichton, who classes it as the first genus in his synoptical table, of which mania and melancholia are species. Foderé, still more recently,† has adopted it as a generic name for every form of insanity. Others maintain, that delirium implies mere raving, and is always symptomatic; and carefully direct, that in marking the diagnostics of diseases where delirium is present or mentioned, that it must always be understood as contradistinctive of insanity.

The late Dr. James Sims, in an excellent essay on mental alienation, treated of delirium as totally distinct from

*First Lines (1535).

+ Traité du Délire, 1817.

insanity and fatuity, and divides it into two species, desipiency and raving.*

Dr. Robert Willis drew a distinct line between delirium and insanity.

;

"In delirium," he says, "the mind is actively employed upon past expressions, upon objects and former scenes, which rapidly pass in succession before the mind resembling in that case a person talking in his sleep: there is also a considerable disturbance in the general constitution, great restlessness, great want of sleep, and a total unconsciousness of surrounding objects."

"In insanity, there may be little or no disturbance apparently in the general constitution; the mind is occupied upon some fixed assumed idea, to the truth of which it will pertinaciously adhere, in opposition to the plainest evidence of its falsity; and the individual is always acting upon that false impression. In insanity, also, the mind is awake to objects which are present."+

The difference between delirium and insanity is here too briefly and generally described to be of much practical utility. This physician, however, regarded delirium and insanity as distinct.

Esquirol has treated of La Folie and Délire in separate articles. He defines the latter thus: "a man is in a delirium when his sensations have no relation with exterior objects, his ideas with his sensations, his judgment and determination with his ideas; and when his ideas, judgment, and determination, are independent of his will.” But he considers delirium only as a sign or symptom of some morbid condition or action, and not as a distinct affection. His disciple, Georget, however, thinks that acute delirium presents all the varieties of insanity, and that it is easily distinguished

* Med. Memoirs, vol. v.

f Parl. Report, 1810.

Dictionnaire des Sc. et Médic. tom. viii. et xvi.

from the delirium of insanity; that both deliria consist in a lesion of the same function, intelligence; but he alleges that they differ essentially in their characters, causes, and progress, as well as in the means of cure; and finally, that it is difficult to confound them, except in some intermediate and rare cases.

Falret gives a just caution against mistaking acute delirium for insanity; and is impressed with the difficulty, though he admits the utility, of defining the limits of each affection.*

The essential difference in the two species of delirium is illustrated by the physiological fact, that delirium is common in many of the acute diseases of childhood, but the delirium of insanity is unknown before the approach of puberty.

In true delirium the imagination is always deceived, which is manifested by optical illusions. That it is only the imagination acted upon, is proved by simply shading the eyes, which will suspend the delirium. A bandage thus placed has suspended particular delusions even for days; but they returned when the shade was withdrawn.† Reil reports the case of a lady who thought she always saw spectres, monsters, &c. and immediately fell into a convulsive delirium; but if her maid even placed her hands over her mistress's eyes, the patient would directly call out, "I am cured." Reil adds, he saw the experiment tried with this effect.

Delirium may be pyretic or apyretic-that is, with or without fever; and, like other morbid actions, may be primitive, sympathetic, or symptomatic. But, though always important, it is sometimes very difficult, to ascertain its real character.

In this country, perhaps, it is scarcely ever an idio

* Essai sur le Suicide, 1822. + Dict. des Scien. Méd. art. Folie. Rhapsodieen, Halle, 1803.