Diagnosis.—The differentiation must be made from mania and melancholia. The affection is frequently confounded with the former. Many cases pro nounced mania, even by expert alienists, belong to the group of acute confusional insanities. Pure mania—that is, typical exaltation without incoherence—is not as frequent as it would appear to be from statistical tables. Worcester puts the matter very clearly when he says "there are two distinct classes of cases, which have in common the symptoms of motor restlessness, loquacity, destructiveness, and violence. In the one (mania) there seems to be, at the outset at least, an ex altation of some of the mental faculties. The patients appreciate perfectly well their surroundings; perception seems preternaturally acute; memory appears to be quickened, so that long-forgotten circumstances are related with the utmost accuracy. The patients show an extraordinary quickness in repartee, and often a diabolical ingenuity and cunning in mischief. They are always ready with an ingenious and plausible explanation of their extravagant conduct. The ela tion which is present is the natural reflex of the feeling of unbounded, unimpeded energy. Hallucinations are seldom, if ever, present; delusions may be entirely wanting, and, if they exist, they are the natural expression of the emotional state. In the other class, on the contrary (con fusional insanity), there is, from the be ginning, evident intellectual impairment, which may exist in any degree, even to an entire failure to rightly recognize any of the persons and things about the pa tient. Memory is impaired or practically abolished; the acts of mischief and violence are done without any apparent purpose, and, when any explanation of them can be obtained, it is utterly irrele vant or evidently founded on some pre posterous delusion. Hallucinations are extremely common, and, with vague, in coherent delusions, dominate the whole conduct of the patient. As a rule, there is no evidence of any feeling of elation.
"The distinction between melancholia and confusional insanity, with depres sion, is of the same sort. The disorder in melancholia is primarily emotional. The patients appreciate perfectly their sur roundings, they recognize persons and things; they can reason correctly on topics indifferent to them if their atten tion can be fixed upon them; their delu sions are the expressions of the over powering feeling of impending evil, which makes everything inconsistent with it seem incredible. In confusional insanity, on the contrary, when there is the feeling of depression, it is the result of the delusions, which are vague, inco herent, and illogical." Many of the cases pronounced "agi tated melancholia" and "melancholia with stupor" are doubtless cases of con fusional insanity.
Prognosis.—The prognosis of acute confusional insanity is generally favor able. While a considerable proportion die from exhaustion under the custom ary methods of treatment, the number passing into dementia is comparatively small. The recovery-rate should be,
under favorable conditions (early treat ment, careful musing), at least 75 per cent. The greatest danger is from ex haustion.
Treatment.—The tendency to exhaus tion being an ever-present one in acute confusional insanity, the first and most important requisite in the treatment is rest in bed. Isolation is not necessary, and, in the opinion of the writer, not de sirable. Patients may at times be treated successfully at home, but where an insti tution is accessible, the chances for re covery are better if the patient is re moved to one.
Nutrition demands constant attention. Easily-digested food in sufficient quan tity must be provided, and the physician should satisfy himself that the patient gets it at the proper times. Forcible feeding is rarely necessary, but many pa tients require urging to eat. Such a one is liable to suffer in the hands of a care less nurse or attendant. Stimulants are often necessary, especially in cases with much fever.
The insomnia and delirium can often be overcome by warm baths, but if the usual hygienic means of producing sleep fail, hypnotics must be resorted to. Of these, opium is to be prefers ed, on account of its stimulant properties. Chloral, hyoscine, and paraldehyde are not recommended, the former on account of its depressant effect the heart, and the two latter because they interfere with nutrition. Next to opium, sulpho nal and trional may be cautiously tried. Digitalis, strophanthus„ and strychnine are often of great value to tone up the depressed heart. The bowels should be kept open by mild saline purgatives.
Tincture of chloride of iron in large doses is often of value. Under proper management, recovery is often remark ably rapid. All sources of toxzumic in fection should be sought for, and if pos sible removed.
Puerperal Insanity.
Definition.—Mental disturbance oc curring in the puerperal period, due to toxremic infection. The clinical form of the disease is usually acute confusional insanity.
Symptoms and Course. — The symp toms of puerperal insanity are usually those of acute confusional insanity. The outbreak of the disease usually occurs in the first week of the lying-in period. It is in almost all, if not in all, cases related to certain well-known symptoms of puer peral sepsis. Fever is nearly always pres ent. Changes in the quantity and char acter of the lochia are frequent. There may be prodromic symptoms, although usually these are not well marked. This consists either in depression, irritability, or emotional instability. The outbreak usually begins with excitement, rapidly ending in incoherence. The usual feel ings are perverted. The patient may have attacks of violence during which at tempts are made on the life of the hus band, the newly-born child, or other children, if there are any. These at tempts often have a religious basis; at other times they are based upon delusions of jealousy.