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twice a day during the past three weeks. During the continuance of these attacks, which come on very suddenly, he throws himself upon his attendants, with whom he is on very friendly terms at other times, in the most violent manner and it requires two or three strong men to restrain him until he can be secluded. He seems to have no remembrance of what has occurred at such times after the attacks have passed.

Again, the disease may assume the form of depression, and patients become suicidal and refuse to take food. When such is the case the procedure necessary to administer it, if undertaken at home, becomes most unsatisfactory and distressing to all concerned.

It may be taken as a rule, therefore, that general paretics should be removed to some institution as soon as the disease is determined, where they can be placed under the immediate care of physicians and trained nurses who are entire strangers to them, and by whom they can generally be much more easily influenced than by their own relatives, and where quiet and skillful moral management will be accorded them.

Medication should have relation to modifying or relieving the conditions which have already been described. Cases attended with cerebral hyperæmia, congestive attacks, and headaches may be treated by cold in the form of ice bags applied to the head, cold baths, and at times with the prolonged bath. The latter should be used with great care and always supervised by the physician. Dry cupping and the application of mustard to the nape and feet may be employed with advantage. Of medicines the bromides are the most effective in the form of a combination of two parts of potassium to one each of sodium and ammonium. I have never had experience with the heroic measures which have been recommended by some authorities, such as bleedings, blisters, and moxas, nor with the practice of creating and continuing an open and suppurating sore upon the neck or back. Patients who have been under my care have not generally been in such a physical state as to warrant such measures of treatment. If they are ever to be adopted it seems to me that the time for their use is at the earliest indications of approaching disease rather than when it has become fully pronounced.

In those cases in which the bowels do not move daily simple purgatives may be given at bed-time, or a movement may be secured by the use of an enema. It is especially important that a costive state of the bowels be avoided, as this is one of the most efficient causes in provoking epileptiform seizures.

I have already referred to the use of the bromides and iodides during the initial period. They may also be used either singly or combined, in moderate doses, for the purpose of relieving sexual excitement, restlessness, insomnia, and congestive attacks. They may sometimes be advantageously combined with digitalis or cannabis indica. When the restlessness becomes very great and the patient is unable to sleep we may give either hyoscine, sulfonal, or the hydrate of chloral or paraldehyde. These inedicines should not be continued generally more than a few nights; if necessary other hypnotics may be substituted for them. Cold applied to the head, or a bath, may sometimes prepare the patient for being more easily and fully influenced by these medicines. The use of opium in any of its forms should be avoided.

For the purpose of preventing both epileptiform and apoplectiform seizures it is especially important that the diet be carefully arranged. While the food should be of a highly nutritious character, it should also be easily digestible and the stomach should never be overloaded; it is better to take a small quantity often. The bromides may be given by enema if necessary; frequent applications of cold to the head and sinapisms to the nape and lower extremities may be of use.

The condition of the bladder should be daily observed and, in case of paralysis, the urine should be drawn with a catheter twice every twenty-four hours.

Bed-sores sometimes become one of the most troublesome complications during the final stage Efforts should be made to prevent their occurrence by the strictest attention to cleanliness and bathing the most exposed parts with alcohol and lead lotion. The pelvis may be supported upon an air cushion so as to avoid pressure on the most sensitive parts. But one of the most efficient preventive measures will be the use of the water-bed. This is indeed a great boon to the unfortunate and emaciated patient. Bandages of soft cotton have been recommended, though I have had no experience with their use.

After the formation of bed-sores they may be treated by the frequent application of charcoal, or some other form of poultices. The parts should be carefully cleansed after their removal with carbolic solution. The permanganate of potash may also be of service, and the granulations may be stimulated by the application of ointments, etc.

LECTURE XXIX.

ACUTE DELIRIUM (TYPHOMANIA). POST-FEBRILE

INSANITY.

Historical References—The Term Typhomania - Definition - Ætiology-Emi.

grationExposure to High Temperature-Physical, Mental, and Alco. holic Excesses—Symptoms- Develop Rapidly-Indications of FatigueInsomnia-Delirium, Character of—Subsides in about Two Weeks, and is Succeeded by Conditions of Semi-stupor-Countenance— Pupils— Tongue - Intolerance of Food and Drink-Pulse---Circulation—Vesicles -Examples—Morbid Anatomy-Diagnosis – Treatment-Post-febrile Insanity-General Remarks on the Delirium of Fevers — Trousseau Delirium in Children-Delirium in Typhoid Fever not of Serious Import – Three Forms of Mental Impairment Following Fever-Relative Importance of Each-Ætiology_Unwise Treatment of Fevers in Reference to Feeding-Symptoms-May be of an Excited or Depressed TypePhysical Conditions are those of Anæmia and Perverted Nutrition-Dr. Hurd's Twenty-three Cases--Cases Following Surgical OperationsHochwart's Thirty-one Cases Following Eye Operations.—The Thirty-five Cases of the Retreat-Prognosis-Generally Favorable-Treatment.

ACUTE DELIRIUM. Dr. Luther V. Bell first directed attention to and presented a paper upon this form of mental disease at the meeting of the Association of Superintendents of American Asylums, in 1849. He described it as a “New Form of Disease," which resembled some of the advanced stages of mania and fever, and yet so far differed from any described form of disease as to render it probable that it had hitherto been overlooked. In 1850 a paper was read before the meeting of the same association by Dr. W. H. Ranney upon “Insane Foreigners," in which he alludes to this form of disease, as described by Dr. Bell, as one of frequent occurrence among emigrants, placing it second in point of frequency among those whom he had treated in the asylum on Blackwell's Island. He describes it as a “form of disease apparently intermediate between mania and typhoid fever," but gives it no definite name. In 1851, Dr. C. H. Nichols addressed a letter to the editor of the Journal of Insanity, enclosing a short communication from Dr. A. V. Williams to himself, in which he (Dr. Williams) gives some account of a form of insanity" which in our conversations and in my reports I have denominated typhomania, from the striking typhoid character of the physical symptoms it exhibits and the treatment required for its cure."

It thus appears that the term typhomania was not that of Dr. Bell, but Dr. Williams, and that it was used, at least in the earlier history of the disease, from the supposed relation it sustained to typhus or typhoid fever. To Dr. Bell, however, belongs the honor of first directing attention to it, differentiating and describing so fully its symptoms and march of progress that subsequent writers have added but little additional information in relation to them. This, however, could not be said in reference to its morbid anatomy, as the modern methods of examination of brain tissues were then unknown. While he suspected pathological changes in the brain from the character of the symptoms, he failed to satisfy himself that they existed, and Dr. J. B. F. Jackson was equally unable to demonstrate such morbid alterations of tissue. The investigations of later students have supplied this deficiency, and have more fully differentiated it from any form of or connection with typhus or typhoid fever.

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