Gynaecological operations should be performed on insane patients only when the physical condition endangers life or renders it insupportable. Patients should be in a calm frame of mind before the operation and previous moral treatment instituted before it is undertaken. A. H. McFarland (Annals of Gynmecology and Ptedia try, Oct., '93).
In all cases where the menstrual epoch acts as the exciting cause of insanity, the ovaries should be removed, even if there is no evidence of local disease. Eliot Gorton (Med. Record, Aug. 25, '94).
Out of 300 castrations, in 200 cases operation had a beneficial effect; in 100 it was doubtful or unfavorable. In 2 personal cases, both said to be cured, same results could have been reached without mutilation. Kraemer (Allge meine Zeit. f. Psych., etc., B. 52, H. 1, '95).
Post-operative insanity is most fre quently observed following gynmcolog ical operations or those upon the eye. But it only occurs rarely. In most cases there is some hereditary psychical tendency. Delirium tremens or senile dementia may occur after operation. Post-operative insanity occurs in women more often than in men, and is very rarely seen in children. Degeneracy pre disposes to it. The general condition of the patient before operation is an im portant factor, as is any cause of emo tion. Psychoses rarely appear before operation from fear of the operation. Finally the anesthetic or the antiseptic used may cause insanity by producing an intoxication, or there may be an autointoxication. Clinical symptoms vary exceedingly. The prognosis, diag nosis, and treatment arc the same as though the condition had not followed operation. The entire literature is cited. A. Pilcz (Wiener klin. Woehen., Sept. 4, 1902).
The details of a number of cases of mental disturbance following surgical operations leave much to be desired on the score of fullness and accuracy. In perhaps the majority of instances authors consider it sufficient to state that "in sanity" followed the operation. How ever, enough is known to warrant the conclusion that several forms of mental disturbance, agreeing in the main with certain prominent clinical varieties of in sanity, are met with as such post-opera tive sequels; but there is no special and distinctive form of post-operative psy chosis.
There can be little doubt that in per sons with emotional instability the shock of a grave operation may produce transi tory delirium, or even more persistent mental aberration. The frequency of the
so-called "transitory mania" at the mo ment of the completion of the second stage of labor is evidence that intense pain, combined with high nervous ten sion, is capable of producing it. The delirium attending severe injuries— "traumatic delirium"—may also in most cases perhaps be ranged with the cases of mental aberration from shock. Those cases of post-operative delirium or psy chosis following immediately after the operation may be classed in this category. That other factors may concur in the production of this form of psychosis— e.g., anxiety, worry, and the like—is • probable. Ahlfeld reported a case of violent mania following the introduction of a speculum, and Kiernan one conse quent on the passage of a catheter in a man. In a small number of the reported cases no other essential factor than the shock and anxiety can be traced. From this form the patient usually recovers.
In insanity following surgical opera tion mental impressions may be produced in three ways: by anticipation, by actual operation, and by after-effects. C. T. Dent (Jour. of Mental Science, Apr., '89).
Three cases of mania after ovarian castration. One of these recovered within a month, while the other two committed suicide. Poirier (Rev. de Chir., April and May, '98).
Among several thousand operations, only five cases of insanity observed, and two of these were insane before the oper ation; a third was in a state of senile dotage; in the remaining two the mania followed upon important operations and was quite inexplicable. The exaggerated fear of operation, which one often meets with in women, is an important factor in the production of mental instability, and is a contra-indication, when very pronounced. Bouilly (Rev. de Chir., April and May, '98).
Gynecological and ophthalmical opera tions are the two kinds most likely to be followed by post-operative insanity. The type usually observed under these con ditions is a transitory form of acute mania, with mental confusion and hal lucination. The majority of cases occur in persons over 40 years of age. The older the patient, the greater the chance of mental disorder. The majority of eases are of short duration, and do not require asylum treatment. Out of 40 cases, only 0 possessed an heriditary predisposition. There were 19 eases of melancholia. S. R. MacPhail (Brit. Med. Jour., Sept. 23, '99).