We had one patient on a medical ward at the Middlesex Hospital, Gerald P., who was dying from kidney failure—his kidneys could no longer clear the toxic levels of urea building up in his blood, and he was delirious. Mr. P. had spent much of his life supervising tea plantations in Ceylon. I read this in his chart, but I could have gathered it from what he said in his delirium, for he talked nonstop, with wild associational leaps from one thought to another. My professor had said he was “talking nonsense,” and at first I could make little sense of what he was saying—but the more I listened, the more I understood. I started spending as much time as I could with him, sometimes two or three hours a day. I began to see how fact and fantasy were admixed in the hieroglyphic form of his delirium, how he was reliving and at times hallucinating the events and passions of a long and varied life. It was like being privy to a dream. At first he talked to no one in particular; but once I started to ask him questions, he responded. I think he was glad that someone was listening; he became less agitated, more coherent in his delirium. He died peacefully a few days later.
In 1966, when I started practice as a young neurologist, I began working at Beth Abraham Hospital in the Bronx, a home for those with chronic diseases. One patient there, Michael F., was an intelligent man who, besides other problems, had a very damaged, cirrhotic liver, the result of a severe hepatitis infection. The little liver he had left could not cope with a normal diet, and his protein intake had to be strictly limited. Michael found this hard to take, and every so often he “cheated” by eating some cheese, which he adored. But one day, it seemed, he went too far, for he was found in a near coma. I was called at once, and when I arrived, I found Mr. F. in an extraordinary state, alternating between stupor and delirious agitation. There were brief periods when he would “come together” and show insight into what was going on. “I’m out of this world,” he said at one point. “I’m stoned on protein.”
When I asked him what this state felt like, he said, “like a dream, confused, sort of crazy, spaced out. But I know I’m high, as well.” His attention seemed to dart about, touching on one thing and then another almost at random. He was very restless and had all sorts of involuntary movements. I had my own EEG machine at the time, and, wheeling that into Mr. F.’s room, I found that his brain waves were dramatically slowed—his EEG showed classic slow “liver waves” as well as other abnormalities. Within twenty-four hours of resuming his low-protein diet, though, Mr. F. was back to normal, as was his EEG.
Many people—especially children—experience delirium with a high fever. One woman, Erika S., recalled this in a letter to me:
I was 11 years old and was home from school with chicken pox and a high fever. . . . During a fever spike, I experienced a frightening hallucination for what seemed like a
very long time, in which my body seemed to shrink and grow. . . . With each of my breaths, my body would feel like it was swelling and swelling until I was sure that my skin would burst like a
balloon. Then when it felt so excruciating, like I had suddenly grown from a normal sized child to a grotesquely fat person . . . like a person-balloon . . . I would look down at myself, sure
that I would see my insides bursting out of my inadequate amount of skin, and blood pouring from enlarged orifices that could not contain my swollen body. But I would “see” my
normal sized self . . . and looking would reverse the process. . . . I would feel like my body was shrinking. My arms and legs would get thinner and thinner . . . then skinny, then emaciated,
then cartoon thin (like the legs on Mickey Mouse in
Josée B. also wrote to me about her “Alice-in-Wonderland syndrome” as a child with fever. She remembered feeling “incredibly small or incredibly large and sometimes both at the same time.” She also experienced distortions in proprioception, her perception of her own body position: “One evening, I couldn’t sleep in my own bed—every time I lay down on it, I would feel I was standing tall.” She had a visual hallucination, too: “Suddenly I saw cowboys who were throwing apples at me. I jumped onto my mother’s dresser to hide behind a lipstick tube.”
Another woman, Ellen R., had visual hallucinations that took on a rhythmic, pulsing quality:
