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sense and the sympathetic ganglia are found to be implicated.*
Treatment. The alienist in charge of an institution, or in consulting practice, is rarely called to examine and prescribe for a general paretic until after the disease has become so far advanced as to be beyond the effect of remedial medicines, except as they may prove to be palliative.
The few cases which have been reported as recoveries after being admitted to an institution are, at the least, somewhat doubtful, and if accepted as genuine would only prove the general rule that recoveries do not occur. Indeed, when the symptoms, physical and mental, have become so far developed as to render a diagnosis certain, already the pathway on which the patient must travel, and even the length of time during which he will very likely be in passing over it, are pretty accurately discernible. On that highway he sees inscribed in the plainest of letters—" Facile deconsus averni”; and also " Nulla vestigia retrorsum." If ever in the previous
“ history of the case there had existed a period during which restorative treatment might have been of avail, that period has now passed, and, therefore, whatever he may be able to suggest will resolve itself largely into nursing and care.
The question now arises whether there may not have existed a period prior to the development of these characteristic physical and mental symptoms when, if the case had been understood, treatment might not have sufficed to avert the entrance on that fatal pathway. If the importance of the initial conditions, attended with headache, depression, languor, loss of interest and satisfaction in the
* For a more extended study of the microscopic appearances of the brain and spinal cord in general paresis, I must refer to the treatises of Spitzka, in our own country, and to Lewis, Mickle, and Voisin, abroad.
pursuit of usual avocations, indisposition to read or occupy the mind, especially with what has formerly been of interest, and the development of a kind of motiveless activity,– if, when these indications began to appear they had been rightly interpreted and an efficient system of treatment had become instituted, might not the system have responded, and the subsequent development of the disease been averted? The late Dr. Tyler was very positive in the belief that he had succeeded in arresting the development of the disease. Others have been equally confident of the practicability of doing so, or at least of postponing its evolution for an indefinite period. But whether it be true or not, there certainly exists no inherent improbability in the view that while the morbid process has proceeded only so far as simply to derange the physiological function of the nerve element, or lessen it, and before it has proceeded so far as to destroy it, measures of treatment may prove efficient in arresting further progress, and in restoring these elements again to their normal state of activity.
It may be added that if such results follow treatment instituted for averting the development of other forms of mental or nervous diseases during the initial stages, we may, at least, expect it will do so in general paresis. But evidently the great difficulty will be in appreciating and determining the significance of the somewhat obscure and doubtful symptoms, inasmuch as they may appear in cases which, without treatment, never eventuate in general paresis. At this stage, the history of the individual as to heredity, habits of life, occupation, mental strain, loss of sleep and morals, will prove an important factor in determining the probable prospect and the course to be pursued. Assuming, then, such a case with an unfavorable history, what measures will be most likely to prove efficient in averting the threatened oncoming of disease ?
The first, and a very essential one, will be a thorough change as to those conditions and habits of life which have appeared to be efficient in producing the threatened attack. For this purpose some new form of light employment may be suggested, or travel, diversion of the mind into other channels of thought, regularity of habits as to sleep and exercise, friction applied to the body and extremities with an effort to improve the circulation of the latter, regularity in the use of a simple and nutritious diet without wine or stimulants of any kind, with an abandonment of excesses in every form, if any have existed. If the patient has been accustomed to an intellectual occupation, this should be abandoned for the time being, and every source of anxiety, worry, and care avoided. Absence from home, and travel with a judicious companion, and visits to new scenes and places which may present enough of interest and novelty to divert and occupy the mind, will prove to be an efficient means of improvement. In short, the business man, the lawyer, the politician, the physician, must each seek for such diversion and change as will probably prove most conducive in withdrawing them from former habits of thought and modes of life, at least so far as may relate to care, anxiety, and responsibility.
An absence from family life and city surroundings, and life out-of-doors in some favorable climate, will be advisable, at least during several months. All subjects of conversation or discussion which will be likely to develop unusual interest or difference of opinion should be most studiously avoided, and yet in such a manner as not to attract the attention of the patient. Indeed, the benefit to be secured from the course of proceeding outlined above
will depend largely upon the skill and perseverance of the attendants and friends who may be about and have the care of the patient. Boundless patience, tact, and devotion will be called into requisition, while the physician should seek to restore disordered secretions, relieve congestions, and calm all nervous agitation and anxiety.
If at any period the therapeutical agencies are to be of any value in arresting the progress of the disease, it would appear to be during the initial period, and the earlier the better. From the fact that a few cases have been reported in which the disease has been arrested, or at least its evolution postponed, by the appearance of a carbuncle, or some form of intercurrent disease, it would appear reasonable to expect benefit from the use of the actual cautery, or from the long-continued application of cupping glasses or a seton at the nape of the neck. The liodide of potassium, with such medicines as may be indicated for the appetite and to secure sleep, will be in order.
The bromide of sodium and ammonium may be given to quiet excitability and restlessness and procure sleep. The iodide of potassium should be used freely in case there exists any ground for a supposed syphilitic basis of the disease. It may be anticipated that by the early recognition of the disease, and by instituting at once some such course of management as is outlined above, favorable results may probably be secured in a few cases.
It should, however, be borne in mind that what has been suggested is of importance only in the very earliest portion of the initial period. If the case has progressed so far that the inherent energizing capacity of the cells of the grey matter, upon which the process of mentalization depends, has become largely impaired, there will be no longer hope of restoring it to a condition of normal activity. As the elements of these cells are the highest and most complex development of the system, so they are the most sensitive in response to unfavorable influences, and are the least amenable to restorative treatment.
After the disorder has become established, and while the patient is still restless and anxious to travel, advice will often be requested by friends as to the desirability of his doing so. In reply it may be stated that generally the more quiet and secluded patients can be kept, the less will become the danger attending excitement and the exhibition of passions. Nor should patients be retained at home with a view of treatment there. They will be likely to still regard themselves as masters in their own houses and decline to place themselves under such restrictions as to conduct, food, and medicine as may be necessary. Another most important reason for placing such patients under restraint arises from the peculiar character of their delusions. This not unfrequently leads to the squandering of property in the most reckless manner and to entering upon large business enterprises which lead to ruin. No class of insane patients are so likely to bring financial trouble upon their families before measures of restraint are instituted as general paretics.
General paretics, when under the influence of delusions of importance, grandeur, and great wealth, if repressed often become domineering and dangerous. This is true while they are under the protection of strangers, and much more frequently the case when the repression is instituted by old friends or the members of their own families. Seclusion, therefore, becomes necessary for short periods or during the continuance of the furious excitement. There is a young man at the time of this writing in the Retreat who has experienced a period of excitement once and sometimes