It will thus be seen what grave responsibility commissions assume when they attempt to "regulate the treatment of the inmates of hospitals for the insane."

There is enough work in the field of lunacy for all who engage therein. From 1815 to the present time is within the memory of men now living and what changes have been wrought! If lunacy boards will take a broad and liberal view of their duties they can awaken in the public an intelligent and growing interest in institutions for the insane. They can discourage sensationalism and disarm unjust and unfeeling criticism and in doing these things their time will be very largely occupied. The little petty details they can well afford to ignore. In avoiding being autocrats let them beware less they become bureaucrats. Let them beware that in looking after the "mint, anise and cummin" they lose sight of the weightier matters of the law "judgment, mercy and faith;" "judgment" as between the garrulous complaints and faultfinding of the chronic scold, the sensational story of the press and the sometimes well-founded charges of some unfortunate; "mercy" toward the insane no matter where found, and "faith" in those who are laboring along the same line of work. The managers and medical officers of our institutions for the insane, public and private, are the men who have suggested many of the reforms which have been accomplished in lunacy administration and who have cheerfully, as they saw the way, worked out the reforms instituted by others.

CONFUSIONAL INSANITY.

BY WILLIAM L. WORCESTER, A. M., M. D.,

Late Assistant Physician Arkansas State Lunatic Asylum, Little Rock.

The matter to which I wish to call your attention for a few minutes is a question of classification. The classification of insanities is confessedly, at present, far from satisfactory, and is likely to remain so until our knowledge is much more complete than now. Those who find the etiological principle sufficient for their needs— to whom, for instance, puerperal insanity, pubescent insanity, masturbatic insanity, and the like, are distinct clinical forms of disease—will probably see no utility in the distinctions which I shall draw. I, for my own part, am unable to use such a classification with any satisfaction. I find very different symptoms in cases due, apparently, to the same exciting cause, and strong clinical resemblances in cases excited by different causes. Doubtless, when we get to the bottom of things, like causes always produce like effects, and the circumstances which I have mentioned lead me to think that the divisions in use in the etiological classifications in vogue are really of minor importance, and that the essential cause is something which is ignored in such systems, and which can not, with our present knowledge, be satisfactorily defined, although we must assume its existence-the defective organization of the patients.

Pathological anatomy, likewise, seems to me to fail in furnishing a satisfactory basis for classification. After giving a good deal of attention to the subject, I have failed to find definite and uniform changes, gross or microscopical, associated with the various forms of insanity that make up the bulk of the population of our institutions for the insane.

I am, then, for my own part, compelled to fall back upon the symptoms and course of disease as the most satisfactory principle of classification now available, and, judging from the reports of our hospitals, I conclude that I have with me, in that opinion, the majority of this audience. In those reports I infer that in most cases the acute, and presumably curable, cases of insanity are generally classified under the two titles of mania and melancholia. I presume, however, that the experience of others is not altogether

unlike my own in meeting, not infrequently, with acute cases which do not fall naturally under either of these heads, and with others which show, at different periods in their course, more or less of the symptoms of both, and with which it is a matter of chance, depending on the stage in which they may happen to be at the time of admission, to which of these categories they shall be assigned.

In a large proportion of such cases the most prominent symptom seems to be mental confusion, and since I have become impressed with the fundamental importance of this symptom, it has, to my own mind, greatly simplified the classification of my cases.

Neither English nor American writers have, so far as my reading has extended, laid much stress upon this symptom. It can not, of course, fail to attract the notice of any one who has much to do with the insane, but, with few exceptions, writers in the English language have treated it as an incident in cases which were classified without reference to it. Spitzka, in his work, has a brief chapter on confusional insanity but speaks of it as a rare condition. The only writer in this country, so far as I remember to have noticed, who has paid very much attention to the subject is H. C. Wood. In the American Text-book of Medicine he defines it as follows: "An acute insanity produced by nervous shock or exhausting disease, without distinct constant emotional depression or exaltation, with marked abatement of mental power (ranging from a mild mental confusion to complete imbecility) often, but not invariably accompanied by hallucinations and great mental excitement; with loss of physical power; usually disturbances of temperature; the whole commonly ending in complete recovery. Synonyms. Primary curable dementia; stuporous insanity; stupidität; delusional stupor; mania hallucinatoria; wahnsinn; surgical insanity; puerperal insanity; post-febrile insanity; mania following typhoid and other acute fevers."

German writers, on the other hand, have of late years, given a good deal of attention to this subject, although with rather a confusing variety of nomenclature, and considerable difference as to the extension which they have given to the application of the terms which they have bestowed upon it. I will not take up your time with citations, but will mention that the most satisfactory treatment of the subject with which I have met is by Schüle, in his "Klinische Psychiatrie," under the title of "Acute Wahnsinn."

The definition given by Wood, and quoted above, is, in the

main, satisfactory to me, although I should not lay so much stress as he does on the etiological factor. Cases excited by the causes which he mentions usually, in my experience, have taken this form, but I have also seen pretty numerous cases, evidently belonging, as it seems to me, under this head, in which neither these nor any other obvious exciting causes could be ascertained. The fundamental symptom, to which, in my opinion, all the other mental disturbances are subordinate, is mental confusion or bewilderment. There is a failure in the natural association of ideas, and, as a consequence, the mind is occupied with vague, inconsistent, and ever-changing delusions. Sensible objects fail to awaken their natural associations, and thus places and persons are not recognized. In a large proportion of cases, hallucinations add to the bewilderment of the patient. Incoherence of speech, very commonly present, is evidently due, not, as in uncomplicated mania, to an overwhelming rush of ideas, crowding upon the mind too fast for expression, but to incoherence of thought-to a failure of natural logical connection between the ideas to be expressed. The most absurd actions are done without any feeling of incongruity. In such a condition of mind it is easy to understand how the emotional tone, imparted by the indefinite and shifting delusions and hallucinations, may vary between elation, depression, and indifferWe may, I think, gain some insight into the feelings of such patients by reflecting on what occurs in our own minds in dreaming-a condition which is usually characterized by mental confusion, with hallucinations, and in which our emotions take their tone from the delusions and visions of the dream. In the early and incomplete stages of anaesthesia, by ether, chloroform and nitrous oxide, again we have a state of artificially produced mental confusion, in which the patients may be elated or depressed, frightened or furious in accordance with their natural disposition, or as suggested by their feelings at the commencement of the administration of the drug, or by some trivial circumstance when coming under its influence. No one would think of calling the elation and depression occurring under such circumstances distinct pathological conditions, and there would seem to be no occasion to do so in the various emotional states of a waking dream. We find, accordingly, that the emotional condition may be as inconstant and variable as the delusions from which it takes its rise. Sometimes the patients wander about, appearing neither elated nor depressed, but

ence.

evidently comprehending very little, or not at all, their surroundings. They may denude themselves, disarrange furniture, throw things out of the windows, evidently without any intention of indecency or mischief, but in obedience to impulses originating in delusions. There may be a lethargic or stuporous state, which may be accompanied by cataleptic rigidity, or by constrained and extravagant postures and movements, as in Kahlbaum's katatonia. In a majority of cases I think there is, at some time, a condition of motor excitement, with tendency to violence, destructiveness, noise, and loquacity, but it is apt to be lacking in the elation characteristic of mania, and the violence is unprovoked and senseless — evidently due to delusions. Apprehensiveness, even to the most abject terror, may be manifest, but there is not usually the sense of personal unworthiness found in melancholia. It is infrequent, I think, for either excitement or depression to persist throughout the whole course of the attack. Most commonly there is, at different periods, an alternation of the one with the other, or with an emotionally indifferent state. A patient who has sat for days in a lethargic condition, perhaps with symptoms of catalepsy from time to time, may suddenly make a violent and unprovoked assault on the person who happens to be nearest to him, or commit some senseless and apparently purposeless act of destruction. A very common symptom is a vague apprehensiveness, leading the patient to resist. everything that is attempted with him--dressing and undressing, feeding, moving from one part of the ward to another.

As to the etiology of this condition, the most important thing, in my opinion, is the constitution of the patient. The nervous shocks, mental and physical, which seem to be its starting-point in a large proportion of cases, have no such effect on the majority of those subjected to them, and it has not been very uncommon, in my experience, to meet with cases of this kind in which no obvious cause could be assigned. Still, this form of mental disturbance seems more likely than any other to follow influences which make a profound impression on the nervous system. So far as I can recall them, all the cases of puerperal insanity which I have seen, all cases following fevers and other acute illnesses, and most of those in which fright, grief, and mental distress seemed to be the exciting causes, have been of this sort. Cases following bodily injuries and surgical operations are, so far as I can judge, strictly analogous to puerperal cases. Most of my cases occurring in young people during