First identified in institutionalized psychiatric populations, chronic excited delirium syndrome was not uncommon in the first half of the 20th century. After a temporal pause, excited delirium re-emerged in the 1980s, in an acute form. Generally occurring in victims without organic mental disease, acute excited delirium is associated with stimulant abuse. This exploratory research examines the evolution of excited delirium deaths in custody to determine if medical examiner cases in Maryland reflect the historical and clinical patterns identified in the existing literature. All deaths occurring from 1939 to 2005, under the purview of the Office of the Chief Medical Examiner, were reviewed. Sixty-two custodial deaths were subsequently identified, all of which documented excited delirium as a cause of death or presented with characteristics associated with excited delirium (eg, endogenous mental disease, drug intoxication, violent behavior, paranoia, or the use of physical restraints). Consistent with extant literature, acute onset excited delirium was first identified in Maryland during the 1980s. These cases generally included violent behavior, drug intoxication, and the use of restraints. In contrast, chronic forms of excited delirium were not clearly identified. This divergent finding may be an artifact of case documentation, case inclusion criteria and/or medico-legal protocol, specific to Maryland.