A second class of post-operative in sanity would appear to be due to the ab sorption of poisonous agents used before, during, or after the operation. It is now generally accepted that the acute mental disturbances, mostly hallucinatory in character, following operations upon the eye are due to the use of atropine and similar drugs. It is not improbable that some of the post-febrile psychoses are at tributable to a similar cause.
These cases of drug poisoning with pronounced symptoms of mental disturb ance are probably not so very rare as sequels; of grave surgical operations, particularly where extensive use is made of chemical antiseptics during the oper ation or in the after-treatment. The ex cessive use of opium, quinine, and other anodynes and antipyretics may with good reason be charged with some of the cases of post-operative insanity. The rare cases of mental disturbance following the administration of anaesthetics may prop erly be ranged under the same heading. One reason for this view is that in the large majority of these cases the symptoms are transitory and recovery promptly follows under appropriate treatment, chief feature of which must be the withdrawal and elimination of the toxic agent.
If we exclude the pseudomania, or de-' Brim]] resulting from alcoholism, from the anesthetic, from iocloform, etc., it. will be found that real post-operative mania is very rare; that the subjects of it, while chiefly met with in gynaecolog ical practice, are the victims of sufficient. mental predisposition to account for its occurrence. Potherot (Rev. de Chir., Apr. and May, 'OS).
No operation really "gives birth" to in sanity. Like the anaesthetic, an opera tion may reveal certain latent tendencies, but does not create them. M. Regnier (Rev. de Chir., Apr. and May, '98).
An anesthetic may be given to the in sane with impunity, as a rule, when operations or examinations are neces sary; but there is danger it may lead' to a fresh attack of insanity if it is given to patients who have had previous at tacks, and to those who are subject to recurrent insanity of any form. G. 11. Savage (Clin. Jour., Apr. 11, 1900).
A third class of cases of post-operative insanity I believe to be due to the ab sorption of septic materials from the wound or surface exposed during the operation. A study of reported eases shows that the insanity in most instances develops several days after the operation and is usually of the clinical variety termed "acute confusional insanity."
The prominent symptoms are insomnia, restlessness, emotional instability; some times sudden, violent outbreaks, followed by incoherence, variable hallucinations, —especially of vision,—and sometimes delusions of grandeur or persecution. In most cases there are symptoms of fever, and usually marked implication of the physical powers. The pulse is rapid and weak, the temperature elevated, the tongue dry and red, and there is, usually, refusal of food. Exhaustion of mind and body rapidly intervenes, and the patient sinks into a state of muttering delirium, coupled with great bodily weakness.
Le Dentu has collected sixty-eight cases of post-operative insanity—thirty eight following operations upon the fe male sexual organs and thirty developing subsequent to general operations. Gen erally, he says, the mental disturbance begins from the second to the fifth day, although in some cases not until the twentieth or even later. He discusses the possible causes of post-operative in sanity, but does not offer a solution of the problem. Bantock, in referring to a case of "hysterical mania" following four or five days after an hysterectomy, says there was "considerable tumefaction of the mamma; to account for the disturbance." Excluding the cases chic to shock, nervous strain, exhaustion, and drug-in toxication, which generally appear within the first twenty-four hours, it is probable that the majority, if not all, of the cases of post-operative insanity coming on within the first week are septic in origin. Puerperal insanity is now generally re garded as essentially a septic psychosis, and in this large and well-studied class of mental disturbances we have the closest analogy to most cases of post operative insanity. It is possible that some of the acute cases following re moval of the uterus or appendages are due to the sudden induction of the meno pause, for so acute an observer as Krafft Ebing considers the onset of the climac teric as a cause of acute delirium. Those cases of post-operative insanity coming on several weeks or months after removal of the uterus or appendages in women may be regarded as essentially cases of climacteric insanity (q. v.). The type is usually depressive. The cases that have been observed after extirpation of the testicles also usually present the melan choliac type.