A CASE OF ACUTE DELIRIUM. 
With some Considerations on its Pathologic Aspects. 
BY 
THOMAS P. PROUT, M.D., 
PATHOLOGIST AND SECOND ASSISTANT PHYSICIAN TO THE NEW JERSEY 
STATE HOSPITAL AT MORRIS PLAINS. 
FROM 
THE MEDICAL NEWS, 
August 18, 1894. [Reprinted from The Medical News, August i8, 1894,] 
A CASE OF ACUTE DELIRIUM 
With some Considerations on its Pathologic Aspects. 
By THOMAS P. PROUT, M.D., 
PATHOLOGIST AND SECOND ASSISTANT PHYSICIAN TO THE NEW JERSEY 
STATE HOSPITAL AT MORRIS PLAINS. 
Authorities are at such variance as to the existence 
or non-existence of brain-lesions in acute delirious mania 
that I deem the following case of especial interest, pre- 
senting as it does both macroscopic and microscopic 
lesions of some import: 
I.. S., a colored farm-laborer, twenty-five years old, 
was admitted to the New Jersey State Hospital at Morris 
Plains, April 27, 1894, with the following history: The 
patient had always been regular in his habits and in- 
dustrious. About one week before admission he sud- 
denly manifested maniacal tendencies, and threatened 
his employer’s life. The authorities immediately took 
him in custody, and after a sojourn of about one week 
in the county jail he was brought to this institution in 
restraint. The patient was so much exhausted that for 
a short while after admission he was very quiet; but he 
soon became maniacal, singing and shouting at the top 
of his voice, and pacing about the ward in an excited 
manner. He slept very little during his first night in 
the institution, and was considerably excited during the 
next day. He took a little food at dinner-time, and 
slept during the following night under the influence of 
paraldehyd. On the next morning he seemed very 
quiet, but listless, occasionally ejecting a quantity of 
greenish, frothy material from his stomach. Nausea 2 
2 
subsided under the influence of small doses of calomel 
frequently repeated, and the man slept fairly well during 
the night. On the following day it was determined to 
feed him, as he had up to this time taken very little 
food, and he seemed to be fast losing ground; he was 
accordingly given a sufficient quantity of milk both 
morning and evening by means of the nasal catheter. 
During the afternoon he was noisy, but slept fairly well 
during the night. 
On May ist the man had slight fever in the morning. 
The tongue was dry. The patient was very quiet all 
day, and seemed on the whole slightly better. He took 
milk voluntarily, and manifested no gastric disturbance. 
His bowels were moved during the day. Nothing 
further of interest occurred till about 3 o’clock on the 
following morning, when the night-nurse sent me a 
report that the patient had suddenly become worse, and 
was apparently dying. Death occurred about twenty 
minutes afterward. 
The following is abstracted from the autopsy records: 
The autopsy was made eight hours after death. The pia 
mater was engorged with blood, but not adherent to the 
brain-surface. The brain-mass, as a whole, was of 
greatly diminished consistence, and on section showed 
marked congestion, although very little blood exuded 
from the puncta vasculosa, which were very numerous. 
The softening seemed general, but was most marked in 
the frontal and parietal segments of the brain. 
On laying open the circle of Willis three thrombi were 
found, one in the basilar artery, successfully occluding 
its caliber; this thrombus was formed apparently from a 
thrombotic shred which had been thrown into several 
folds by the blood-stream, and had received some recent 
additions in the way of dark clotted blood. The two 
thrombi in the middle cerebrals were much smaller, the 
one on the right side being the larger of the two, but 
neither successfully occluded the caliber of the vessel. 3 
The longitudinal sinus contained an ante-mortem 
clot, which did not, however, occlude the caliber of the 
sinus. The heart contained a large thrombus in the 
right auricle, firmly attached to the tricuspid valve, and 
occupying about one-third of the space in the auricle; 
a smaller thrombus in the right ventricle, extending up 
through the pulmonary orifice; a similar clot in the left 
ventricle, extending up through the aortic orifice; and 
also one in the left auricle, firmly attached to the mitral 
valve. The stomach presented three ulcers, one along 
the lesser curvature, of very recent origin, midway be- 
tween the pyloric and cardiac orifices, and two smaller 
ones near the pyloric orifice, each about the size of a 
dime. These were apparently the older. 
This case is interesting from a pathologic standpoint, 
on account of the unusual lesions found to account for 
the symptoms and the patient’s unlooked-for death. 
Considering the man’s age and his previous healthy 
condition, it seems not improbable that his sudden 
manifestations of violence were coincident with the 
occurrence of partial thrombosis of the basilar artery, 
the mania being due to the serious disturbance in the 
cerebral circulation, and consequent impairment of nu- 
trition in the ganglion-cells of the cortex. The circula- 
tion was still more seriously impaired when the throm- 
botic shreds in the middle cerebral vessels became 
thrown into folds and seriously narrowed the lumen of 
the vessels, and death was to have been expected as 
soon as the cerebral blood-supply became sufficiently 
limited by the gradually increasing obstruction to the 
vascular stream. 
The microscopic appearances of the cortex were of 
interest, because they were unlike the conditions found 
in three cases of acute delirious mania examined pre- 
viously, and all of which presented the same lesion. 
The protoplasm of the cell in the neighborhood of 
the nucleus was almost invariably vacuolated, the de- 4 
Fig. i. 
A. Vacuolation of protoplasm of cell; nucleus hazy in outline 
(upper portion). B. Marked vacuolation of protoplasm of cell; 
nucleus small and hazy in outline. (Zeiss imm. obj., Abbe 
camera lucida.) 5 
gree of vacuolation varying from two or three small, 
rounded, light areas to large clumps of these (Fig. 1), 
Fig. 2. 
Vacuolation of protoplasm of cell and nucleus. (Zeiss imm. 
obj., Abbe camera lucida.) 
which in many instances seriously invaded the nucleus, 
and in a few almost entirely replaced it. (Figs. 2 and 6 
Fig. 3. 
Nucleus almost entirely replaced by vacuoles. (Zeiss imm. 
obj., Abbe camera lucida.) 
3-) The changes in the nucleus were quite extensive, 
but not general; when present they were quite well 7 
marked. In very many instances the nucleus was ap- 
parently swollen; in these cases it was always very 
irregular in outline, but the edges were sharply defined. 
(Fig. 4.) In other instances portions of the circumfer- 
ence of the nucleus were sharply defined, while other 
portions were very hazy, shading off gradually into the 
protoplasm of the cell (Fig. 1, b). In many other in- 
Fig. 4. 
Enlarged and irregular nuclei. (Zeiss imm. obj., Abbe 
camera lucida.) 
stances the nucleus was seriously encroached upon by 
the morbid process in the protoplasm (Fig. 2) ; in a few 
instances being occupied by one or two vacuoles, while 
in a few others it seemed almost entirely destroyed 
(Fig. 3)- 
The microscopic appearances are of especial interest 
when considered in connection with three other cases 
of acute delirium that have come to autopsy in this 8 
institution in the past year and a half, because of the 
entirely different nature of the predominating micro- 
scopic lesion. In these latter cases pigmentary degen- 
eration of the ganglion-cells was the most prominent 
feature, being widely distributed and extremely well 
marked. In the case under consideration there was not 
the slightest trace of pigmentary degeneration anywhere 
in the cortex; in fact, the normal deposit of pigment 
seemed absent from most of the cells. 
In considering the apparent variability in the patho- 
logic phenomena presented by these cases, I must con- 
fess that the cause for such variability is not entirely 
apparent; nevertheless we have to consider the fact 
that while the case was undoubtedly one of acute de- 
lirium, the nature of the delirium differed somewhat 
from that of cases ordinarily seen, in that it showed a 
marked disposition to be transient. We must also bear 
in mind the lesions existing in the vessels at the base 
of the brain as having a modifying influence on both 
symptoms and pathology, no such factor figuring in any 
of the previous cases. 
In connection with this case the work of Dr. H. C. 
Hodge, of the Clark University, is of exceeding interest. 
In his study of the changes in nerve-cells after func- 
tional activity he demonstrated vacuolation of consider- 
able extent as occurring in the nerve-cell after normal 
fatigue, together with considerable shrinking of the 
nucleus. In this case there can be little doubt of the 
existence of extreme fatigue, as the patient was inclined 
to violence, and often made night and day hideous to 
those with whom he was associated. Bearing this in 
mind, the question of the pathologic significance of the 
phenomena under consideration is an interesting one. 
Are vacuoles in nerve-cells of any pathologic import, 
or is their presence simply an indication of the expendi- 
ture of nervous energy ? As a partial answer to this 
question we should bear in mind the occurrence of the 9 
most extreme degrees of vacuolation of nucleus and 
cell-body in primary and terminal dementia, forms of 
insanity uncharacterized by mental or physical activity 
of any description. The same might be said to a lesser 
degree of the different forms of melancholia. On the 
other hand, the occurrence of vacuolation in epileptic 
and some other forms of insanity is well known, and 
according to Hodge it occurs also as a direct result of 
physiologic fatigue. 
In mental disease the nucleus is most often the seat 
of the morbid process, while in physiologic fatigue the 
protoplasm of the cell-body is chiefly affected. The 
forms of vacuolation also differ widely. In the condi- 
tions studied by Hodge the vacuoles seemed evenly 
distributed through the nerve-cell, while in the case 
under consideration the vacuoles were grouped together 
in masses, in the neighborhood of the nucleus, and in 
some instances involved the nucleus also. It would 
seem, therefore, that we may consider cellular vacuola- 
tion, aside from any physiologic process, as a pathologic 
factor in insanity of some importance. 
In conclusion, the proposition may be made that in- 
terference with the cerebral circulation may give rise to 
maniacal outbursts as a direct result of nutritional dis- 
turbances in the ganglion-cells of the cortex. Nutri- 
tional disturbance is manifested, first, in the brain, by the 
marked diminution in the consistence of the cerebral 
mass, and, second, in the ganglion-cells, by vacuolation 
of the protoplasm of the cell-body, and in fewer in- 
stances of the nucleus also. The Medical News. 
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