CHAPTER X.

THE ACQUIRED INSANITIES.

By the acquired insanities we understand those forms that are possible in normally developed individuals without special hereditary or congenital defect that would more or less inevitably tend to the production of mental disorder under favoring conditions. It is not intended to restrict this class exclusively to normally constituted individuals, or to exclude predisposition. They are as liable to occur in predisposed or degenerative cases, and even more so; but this special type of insanity is such that it might occur in any one with sufficient external cause. It is the type, not the etiology or the constitutional conditions and predilections of the patient, that rules the classification.

There are included in this division the mental disorders from exhaustion and auto-intoxication, which can best be considered together, as both causes very commonly cooperate in the etiology of the insanity; the strictly toxic insanities due to poisons introduced into the system from without, the organic and traumatic insanities caused by gross organic lesions of the brain, and, lastly, the insanities of the neuroses, which form a sort of transition to the next following class: the insanities of critical periods, or those occurring at special developmental stages when the special stress upon the brain and nervous system is in excess. Taking them up, therefore, in the above order, we have first to consider the exhaustional and auto-intoxication types.

PRIMARY CONFUSIONAL INSANITY.

Definition. By primary confusional insanity we understand a form of primary mental disorder characterized especially by marked intellectual impairment, delirium, incoordination of ideas, impaired consciousness, and generally hallucinations and illusions, and sometimes a more or less stuporous condition, occurring, as a rule, after severe mental or physical exhaustion, or auto-intoxication in disordered states of the organism.

The simplest and most familiar type of the disease is the temporary delirium of fever, which is hardly recognized as insanity, and which, in the vast majority of cases, passes away without causing permanent damage. In cases, however, that properly fall in the category of confusional insanity, the direct auto-intoxication is less acute, and the damage to the mentally functioning brain elements is much more serious. It stands in about the same relation to febrile delirium that the more lasting alcoholic intoxication or alcoholic mental derangement does to acute intoxication, except that it is not so commonly preceded by repeated temporary attacks. As alcoholic insanity may occasionally occur in steady drinkers who seldom or never exhibit the symptoms of acute inebriety, the parallel is not so incomplete.

While the symptoms of this type of insanity have long been recognized under one form or another, for its acceptance as an independent species of late years we are largely indebted to the Germans, with whom it has passed under various names, as amentia, acute hallucinatory "Verwirrheit," etc. Spitzka (1877) in this country was one of the very first, if not actually the first, to recognize and describe its typical form as an independent entity. Chaslin (1895), "La Confusion Mentale Primitive," has given an excellent monograph on this subject, in which the historic data are very

fairly summed up, and it does not appear from it that any author really antedated Spitzka in the first edition of his excellent manual on insanity, published in 1877. At the present time it has not yet commonly won a place in asylum statistics, but its general recognition is probable in the near future, the more so since it has the sanction of some of the more recent foreign treatises, such as those of Kraepelin and Agostini.

As here understood, the species is more comprehensive than is that of Kraepelin, whose "collapse delirium," acute "Verwirrheit," and dementia acuta are here all included under the same general head of primary confusional insanity. It has seemed better to do this, to consider them as varieties of one species, rather than as distinct clinical forms always recognizable, and not so intimately related as we must admit them to be. They have, in the main, and as acute conditions, the same etiology, and, as Kraepelin admits, the same marked disorders of understanding, of connection of ideas, and of the mental reaction to external impressions and representations. Their treatment is practically the same, only varying with minor and special individual conditions. They graduate also into each other, so that every variation can be found. between the most excited collapse delirium at the one extreme, to almost absolute stuporous insanity at the other. To quote Kraepelin again, his acute "Verwirrheit" can, in a certain sense, be called a prolonged collapse delirium, and his acute dementia may begin with the characteristic symptoms of either of these types.

With this more comprehensive concept of confusional insanity it is therefore necessary to recognize as phases or varieties of the disorder the more striking modifications of the type. This, however, need not be done formally under different heads, at least as regards the first two, the "collapse delirium" and the acute