Closely identified with the various states of mania previously referred to are the insanities due to toxic influences.

These include a wide range of clinical phenomena associated with the pernicious effects of the various infections, such as typhoid fever, pneumonia, la grippe, malaria and the exanthematas, as well as different drugs, like morphia, cocain, etc., together with chemical poisons of different kinds like alcohol, lead and arsenic. Such insanities represent all ages and conditions of mankind, hence are no respector of persons and consequently are found frequenting the rural stately homes of the millionaire and other classes of society as well as the tenement slum districts of our large cities.

By virtue of their extreme prevalence and commonplace etiology the toxic insanities appeal more often to the general

medical practitioner for relief than any other class of mental disorders-save one, viz. incipient melancholia-while their insidious origin and baleful character cause them to present unusual features which are chiefly of medical, legal and sociological interest. Moreover, such mental disorders may or may not be accompanied with fever, delirium or both. Hence they may precede, accompany or form the sequella of the toxic insanities depending upon their character and class.

Thus we find symptoms of mental disorder arise in connection with febrile states and delirium may replace or be immediately followed by mania, accompanied with or without fever. For instance, mania may succeed the delirium of drink, the delirium of pneumonia or of other specific fevers; symptoms of in

sanity may also be associated with the outbreak of incubation of scarlet fever and smallpox, the mania disappearing with the full development of the rash. Hence fevers and feverish states may be followed by temporary or permanent weakness of mind like loss of memory, deafness, blindness, besides other serious intellectual and moral perversions.

The acute delirium or mania, however, that precedes, accompanies or follows. such febrile states have many features in common, but others in particular, which differentiate them. On account of the many points of difference from ordinary acute mania it may prove useful to first describe

ACUTE DELIRIOUS MANIA, DELIRIUM GRAVE

OR BELL'S DELIRIUM.

This mental disorder has many distinct points of difference from ordinary acute mania. For instance, it is characterized by a febrile state which usually runs very high and associated with an extremely acute delirium. There are, however, no surface lesions present such as are found in the exanthemata, nor are there any signs of visceral insolvent such as belong to pneumania or meningitis. There is, however, frequently a history of insane inheritance, while the outbreak itself is usually sudden, or the transition from indolence or melancholy to mania is exceedingly rapid and unexpected.

It

"Dercum" does not hesitate to hazard the opinion that acute delirious mania or Bell's delirium is a disease due to a specific infection, the bacteria or toxines of which expend their action upon the brain without giving rise to lesions of the cutaneous surface or of the viscera. is, however, possible that this affection is due to a variety of causes. "Savage," in his recent work on "Insanity and Allied Neuroses," claims that the maniacal outbreak generally has some definite. cause and may suddenly follow a shock, a grief or on some physical disease, such as pneumonia or a fever-or, in fact, on any condition resulting in great exhaustion. In describing the disease he states

that the patient is more restless than in ordinary mania and the insomnia is more constant. The language more incohereerent, there being no continuous trains of thought excited by sense impressions from without. The patient usually lies on his back muttering with flushed face, high temperature increasing toward and during the night. Small and rapid pulse, with labored respiration and every evidence of extreme illness.

All food is refused, there appearing to be pain in swallowing, tongue is dry, cracked and leathery, while the lips are covered with dry brown sordes. Constipation is the rule with diminished secretions, there being no sweating, while the urine and feces are passed involuntarily. Masturbation is common and bedsores form rapidly. Profound and rapid exhaustion occurs with wasting and death occurs in a few days in at least 10 per cent of the cases. The patient, however, may pass into a condition of profound physical weakness, associated with mental torpor and even paraplegia or contraction of the lower extremties. The distinguishing clinical features of this disease are according to "Savage."

9. Memory often wanting. 10. Result often fatal.

ACUTE MANIA.

1. Cause doubtful.

2. Onset gradual.

3. Temperature nearly normal. 4. Appetite capricious.

5. Wasting much less, no weakness. 6. Pale or sallow complexion.

7. Hallucinations more persistent if present.

8. Incoherence associated with sense impressions.

9. Memory present, often influenced by the surroundings.

10. Results mostly favorable.

TREATMENT—In the way of treatment "Savage" claims the early administration. of abundance of easily assimilated food is of first importance. "No sentiment should withhold the physician from feeding artificially. Such a patient requires half a pint of fluid food every three hours, night and day, during the exhausted period."

Milk and eggs form the sheet anchor for this, with arrowroot, beef tea, mutton broth and other forms of meat extracts and with each meal "Savage" recommends the giving of some stimulant, equal to about half an ounce of brandy. The idea, he claims, that in such cases brandy or spirits of any kind will affect the brain injuriously is a mistake. If such patient is to be treated at home it will almost certainly be necessary that he or she should have some form of sedative.

Bromide of potassium, in some cases, seems to be specially indicated, its supposed effect in suppressing sexual desire making it useful. I have sometimes given, he claims, half-drachm doses of bromide of potassium as injections, by this means succeeding in calming the irritability of the mucuous membrane of the vagina, and, if seen sufficiently early, before there is much weakness, these cases may be benefited by baths of from 98 to 120 degrees; the higher the temperature, the shorter the time the patient must be retained in the water. frequently prescribe baths of 100 de

I

grees night and morning, each of one hour's duration. The prolonged warm bath is also useful, as are sub-cutaneous injections of physiological salt solution as prescribed under melancholia (p. 207). Chloral may be given with the bromide. of potassium, or alone, in doses not exceeding thirty grains to begin with.

"Savage" also says: "I personally do not like chloral in these cases, for many reasons, one being that it has a tendency to make patients who are still taking their food suspicious and inclined to refuse it. Occasoionally, in cases of extreme weakness, I have given chloral and brandy combined, with considerable benefit. The other sedatives, such as paraldehyde, amylene hydrate, will in some cases be of service. I have failed to see good results from local or general counter-irritation, or from the application of ice to the head. I should, however, add that some physicians of large experience believe that in chloral they have a means of combating this disease.

The importance of good nursing and individual attention is especially great.

"From what we have seen it will be clear that the diagnosis of acute delirious mania may be difficult. The chief diseases for which it may be mistaken are typhoid fever, meningitis, the later stages of some febrile disease, such as rheumatism with hyperpyprexia, and alcoholic delirium. In this disease there is rarely, if ever, intolerance of light, complaints of pains in the head, or vomiting, thus separating it from meningitis, and there is no tendency to diarrhoea, no enlargement or tenderness of the abdomen, as there would be in typhoid fever, and nowadays the agglutination blood test would be employed in diagnosis. In alcoholic delirium there would be the history, the fears and suspicions exhibited, with less impairment of consciousness and, physically, the tremors. The disease may kill and, as I have said, it is of a much more fatal malady than ordinary acute mania.

"Patients may get well, or they may pass into a condition of weak-mindedness after the acute attack. I have, however, never seen a case suffering twice

from this condition, for though, as I have said, I have seen cases suffering from some form of insanity with a history of brain fever before, yet I have never come across a patient with a relapse of delirious mania. There is a great tendency in these patients, if they do not recover, to pass into a state of chronic weak-mindedness with excitement; they will suffer from general incoherence, and may live for years."

DELIRIUM, CONFUSION, STUPOR.

In an article* "Dercum" has clearly shown that closely associated with all forms of toxic insanity are three symptoms which are present in all degrees of intensity, viz., delirium, confusion and stupor. The importance of this fact to the general medical practitioner is at once observed as no physician can practice medicine very long without coming in contact with such an elementary clinical phenomena as delirium. For instance, a child has an attack of fever and the physician observes that it is confused, that it does not recognize its surroundings, that it cries out, that it shrinks, struggles, acts as though it heard strange sounds and saw strange objects. Moreover, it grows more restless and mentally disturbed beside incoherent and finally becomes delirious and later may have illusions, hallucinatios and delusions with more or less stupor.

Not only does such clinical phenomena obtain on childhood, but such symptoms are found associated with delirium at all ages and from whatever cause; hence they are present in every form of delirium and in these essential particulars the conclusion is, that all of the deliria are alike. Moreover, such symptoms may not only accompany, but also follow such febrile states, hence they quite often appear as post febrile phenomena or the sequella of such infectious fevers. The deliria, therefore, seen in medical practice naturally divide. themselves into the febrile and afebrile forms. The former accompany the va

*Journal Nervous and Mental Diseases, Vol. 26.

rious acute infections, the exanthemata and the various active visceral diseases while the afebrile diseases are those which are met with as the sequella of the various infectious diseases. The intoxications, like alcohol and lead, and even those due to trauma or shock. The important association of delirium, confusion and stupor with the various forms of toxic insanities has been so clearly demonstrated by Dercum that I cannot do better than quote from the able article referred to as follows:

"Delirium is essentially an acute mental confusion of relatively short duration-a few hours, a few days, or at most a week or two. Naturally the morbid state which is most closely allied to delirium is the one in which confusion is less active, but more prolonged. Such a state is found in the prolonged cofusion which every now and then comes on in infectious diseases after fever has subsided. It is seen typically in the confusional insanity following typhoid fever, influenza, erysipelas, acute articular rheumatism, the puerperium, profound exhaustion, trauma, surgical shock, etc. Into its causation there enter especially two factors, first, the toxines of infection or other poisons, and secondly, profound and persistent exhaustion. Its symptoms do not differ in any essential particulars from those of delirium save that they are less acute and the course of the disease far more prolonged. In confusional insanity-the amentia of Meynert, the l'erwirrheit of other German writers-there is the same presence of illusions and hallucinations, the same marked confusion and incoherence, but cerebral activity is never aroused to the same high pitch, and while delirium lasts from a few hours to a few days or more, confusion may last two or three months or more. The various forms of confusion are closely allied to each other, just as are the deliria, and no sharp distinctions can be drawn between them. However, special forms may bear the impress of their causation. Thus a confusional insanity following typhoid fever presents a somewhat different clinical picture from the confu