CHAPTER XVIII. TREATMENT. (Part 1)

CHAPTER XVIII. TREATMENT. !• Prophylactic Treatment, {a) Hereditary Pre- disposition. — Prophylactic treatment, without doubt, would be the most important division of treatment, if it could be made effective, because it reaches not one life alone but many. The first consideration, then, in the treatment of general paresis, is the eradication of any tendency towards hereditary predisposition. While general paresis is not so largely a hereditary disease as some of the other forms of insanity, yet even here the fruits of a weakened nervous constitu- tion tell on the next generation with no abatement of force. We find that in a large number of paretics the brain is defective from birth, so that while the parents for the most part have not been subjects of the disease, paresis in the offspring has resulted from a vitiated state of the brain, entailed by other neuropathic con- ditions in the parents. Profiting by the general knowledge in the preven- tion of hereditary diseases, many of the ills of life could be escaped, if medical men in general practice, with courage equal to their convictions, would assert the dangers of the neuropathic predisposition. The physician is, and must be, the conservator of the pub- lic health and, looking to the welfare of posterity, he should use his influence to the utmost to root out any preventable tendency to weakness and disease in the race. Clearly it should be his duty to impress strongly on the minds of his patients the necessity of the avoidance of the marriage of neuropathic people. 267 268 TREATMENT. With less forethought than the breeders of cattle, we never raise our voice against the " sowing of tares," in the pernicious habit of indiscriminate marriage of the " unfit/' Never has there been a time when the teachings of the medical profession have claimed more attention than to-day. This condition is largely due to an intelligent public, who by their wide general reading and consequent application of scientific truths, are ready to heed the warnings thus pointed out, which a generation or two ago would have fallen on deaf ears. This state of affairs is the good soil on which the family physician should not neglect to scatter his seed of good advice most faithfully. It is only by the development of a healthy public sentiment that such good can be accomplished, for laws will never be enforced unless in harmony with the ideas of the community. Hence legislative action should follow, not precede, public sentiment. Later, cautious legis- lation can crystallize the sentiments developed in a community by the concerted action of thousands of physicians. (6) Individual Predisposition. — A more active field promising more immediate results, is the removal of individual predisposition. The children already endangered by a vicious heredity should be given, so far as possible, a balance against the onset of disease. The earlier this is established the better; herein lies one of the oppor- tunities of the physician. He may do much towards securing for the individual a healthy body, if he insists that self-control, freedom from excitement and over-tire be maintained; that a healthful moral and intellectual training shall be given; and that well- balanced mental powers be developed with broad- minded judicious habits of considering religious, TREATMENT OF THE ESTABLISHED DISEASE. 269 social, and intellectual subjects. The energies should be directed into proper channels and later the lesson be taught that strain of worry or excess of any kind is poison to mind and body. In many cases should be emphasized the dangers from the over-strain and over-living of the twentieth century civilization, resulting not only in paresis, but in the many forms of neuropathic heritage. Thus the physician should enlighten and warn; and by every prophylactic means in his power strive to ward off the encroachment of this dire scourge of modern times. (c) The Threatened Attack. — A still broader field of prophylactic treatment is the actual prevention of an impending attack of general paresis by removing the patient from the circumstances or environment under which premonitory symptoms have been ob- served and regulating the life so that such an attack is lessened or removed. This means the regulating of every movement of the patient, the removal of all strain or excess, the use of regular bodily exercise, early hours for retiring, massage and bathing, the gentle use of the intellectual and moral faculties, the avoidance of wines, tobacco and coition. It is abso- lutely essential to cut the patient off from severe work and anxiety and yet judgment must be used. It may require a determined effort on the part of the physi- cian but he should not be disheartened or rebuffed by the patient's environment but gently and firmly force him into other life. It is not necessary to do this hurriedly or ill-advisedly but by degrees the patient can be made to do things that might be deemed absurd or impossible if forced upon him in an injudi- cious manner. 2. Treatment of the Established Disease. — The very early stage of the disease is the one that presents op- 24 270 TREATMENT. portunities most favorable for treatment, and the only period in which hope of permanent relief can be as yet entertained. The care of general paresis, nat- urally, divides itself into the hygienic management of the case, as separate from the strictly medical treat- ment. As the former life of the paretic is, in a large de- gree, responsible for his breakdown, the causes that have brought on him his misfortune must be closely studied and the axe laid at the root of the tree. By attention to healthful means the general tone of the system can be built up, and by a judicious regulation of the habits and life of the patient much can be done, at this time, to check the impending tendencies of the malady. The stress of the environment, or of busi- ness strain, if ever relieved to the benefit of the patient, can best be accomplished at this period, if the friends are tactful in their influence. In some cases the patient may even be informed of the gravity of the results, if he persists in his course of worry or excess, and if he be at all in a condition to be swayed by wise motives, he may be brought to a realizing sense of the folly of his ways. If at this stage, freedom from mental anxiety, change of scene, and a personal interest in other less absorb- ing surroundings, can be secured, together with hygienic conditions of living, there is fair prospect that healthy cerebral activity may be restored and sufficient force acquired to thwart the advance of the morbific processes. One author says : " More or less complete arrest of the disease may be favored by the recognition of its early stage, and by treatment which practically amounts to putting the brain in a splint, as it were." Voisin in France and Meynert, among the Germans, have expressed a confident belief that paresis is susceptible of cure in its early stage. Mey- TREATMENT OF THE ESTABLISHED DISEASE. 27 1 nert based his belief on the theory that preceding and causing the diffuse cortical encephalitis, there is a functional vaso-motor disorder, which he considered curable. The means here to be pursued are much the same as those which are employed as prophylactic meas- ures. It implies a careful oversight and control of the details of the patient's living; work, both mental and physical, reduced; the removal of all stress and strain; abstemious habits of living, such as the avoid- ance of wines, tobacco and coition; the use of mild bodily exercise, early hours and watchful care of sleep; a suitable diet and very careful attention to the state of the bowels; the application of massage and a systematic course of hydrotherapy, combined with the partial "rest cure." In certain cases elec- tricity in some of its forms will be found of advantage. The physician must not yield to any discouraging ex- igencies in the patient's surroundings, but gently and firmly, by the influences at his command, direct the life of the patient into more wholesome channels. If there is impaired health the bodily functions should receive attention, the general condition built up, with tonics if necessary, and such plan of treat- ment instituted for this end, as best meets the views of the individual practitioner. But rest, fresh air, wholesome food, moderate exercise and regular hours will be found to be, as ever, the greatest restorers of energy. Even in suspected cases, where the diagnosis has not been fully made out, it is well to advise rest; and in most cases removal from the daily occupation and surroundings. At this time the question of travel will force itself on the attention of the physician. The word " travel " is attractive to the mind of the over- worked practitioner and patient; in truth, it has a 272 TREATMENT. sweet sound to most ears. But it is now generally recognized that travelling of any kind is conducive to more harm than good to a paretic patient, attended with its hurry, annoyance and excitement. There can be no doubt that a change of environment will always be of benefit; but the special form of the change must be left to the discretion of the advisors, in each individual case, which must be decided in accordance with the circumstances. Danger from suicide, or assault, may have to be guarded against, and the very prevalent risk of dissipation of property should be ever kept in view. If the removal from home, in the early stage, should involve the loss 01 income, or be a serious interference in business, so that the anxiety resulting would be of greater injury to the patient, then a lightening of labor alone may be insisted on, together with the adjustment of the home life. The subject of food needs further elucidation. In the first stage, when there is much excitement, the diet should be light and easily digestible, and abso- lutely prohibitory of alcohol in any form. It will be difficult to insure temperate eating and drinking, for the appetite, always large, is frequently so voracious that nothing short of over-repletion will satisfy the patient's desire. In the later stages the nourishment should be more generous. Milk and eggs may be placed at the head of the list. These articles of diet can be prepared in many ways, so as to prove tempt- ing dainties to the sick. Vegetables, celery, aspara- gus tops, and fruit should be freely allowed. Meats on the other hand should be restricted. Owing to paresis of the muscles of deglutition much care must be exercised that the patient does not choke, or that food is not introduced into the trachea. By easy gradations the food administered must pass from solid GENERAL MEDICAL TREATMENT. 273 to minced and from that to liquid form, in the last months of his life. Alcohol, which at first is with- held, may be given with benefit in the third, or last, stage. As stated under etiology, there is at present a strong trend in the belief among psychiatrists towards the theory that general paresis is an affection due to chronic toxemia. There are indications also that the poison is of bacterial origin through the digestive system. These observers uniformly teach, whether they believe the primary process to be nervous or vas- cular, that the natural immunity of the gastro-intes- tinal tract is modified by the breaking down of those forces which control normal metabolism. The light that recent physiological chemistry and bacteriology has brought to the solution of this problem may soon mark the pathway to remedial measures, such as specific serums or other antitoxins, that will neutralize the influence of these poisons which gain access to the circulation. If this hypothesis should be confirmed it is not improbable that this malady, thus far fatal, may be transferred in a few years to the list of curable diseases. General Medical Treatment. — As yet there is no spe- cific drug or class of drugs which can be regarded as at all remedial in character. This should not be a cause for discouragement, however, for much may be done to alleviate the various conditions and to retard the progress of the disease. It is necessary to bear in mind always that the most unaccountable remis- sions may appear from time to time, even in the final stages, so that the physician's eftbrts should not be relaxed, or his prognosis, as to the immediate results, be too gloomy. The plan of treatment suggested in the prodromic period should be continued and it is 274 TREATMENT. well to remember that in an affection which promises so little from the use of drugs the hygienic and mental management of the case, together with effi- cient nursing, hold the chief place in the treatment. In making a review of the therapeutic history of general paresis, one becomes clearly convinced of what a mighty struggle there has been waged against this formidable disease. It would seem that there is scarcel)' any drug or remedial measure, at all applic- able, that has not been brought to bear against it. Counter-irritation, derivation, revulsion by blisters, suppurants, cauteries, or setons to the neck, spine or scalp; venesection^ and leeching; and repeated paintings with iodin have been faithfully applied but should be rejected as too severe and of doubtful utility. Veratrum viride, tartar emetic and diuretics; nitrate of silver, zinc, physostigma, papaverine and apomor- phia, have had their adherents in the past, but are seldom resorted to at the present day. We mention them in order to call attention to the fact that, now and then, some good has resulted from the use of them. Tonics. — In many cases, in the early stages that are free from excitement, there are indications for the use of tonics, and most cases call for this plan some time during the course of the disease, especially if the patient be enfeebled, emaciated, exhausted or phthisical. They should not be given indiscrimi- nately, much skill can be displayed in the choice of them, which must be left in great measure to the judgment of the attending physician. Among the most prominent may be mentioned the preparations of iron, the vegetable tonics, cod-liver oil, the hy- ^ A man who had decided to commit suicide by letting his blood, felt so much better after considerable blood had escaped, that he had the wound bound up again. Also a gentleman greativ depressed in mind who was being bled ; as the blood flowed, he gradually changed and finally began to joke, etc. (Abstract, Sankey, op. cit,, p. 311.) GENERAL MEDICAL TREATMENT. 275 pophosphites, quinine, strychnia, arsenic and phos- phorus. The number of elegant pharmaceutical for- mulas containing these in various combinations in the market is legion. Sedatives. — There is a long list of drugs of this class, which would carry us into too great prolixity to discuss separately. The selection or combination used is susceptible of a widely varying discriminat- ing choice. The chief ones are: Opium, morphine, bromides, chloral, cannabis indica, veratrine, hyos- cyamin, hyoscine, duboisin, sulphonal, trional, hypnal, tetranal, paraldehyde, chloralamide, antipyrin and chloretone. Ergot ^ Ergot in. — Ergot or ergo tin has enjoyed some reputation, when administered continually for a long time, in moderate doses, in relieving the cere- bral congestion, underlying excitement, and in ward- ing off congestive seizures, but its value has not been uniformly apparent and it has fallen into general disuse. Digitalis^ Digitalin. — Digitalis has been em- ployed by French and English physicians, to combat maniacal excitement, and the tendency to cerebral congestion, with fairly good results, but there are drawbacks and dangers to its use that seem to check enthusiasm. Antisyphilitic Remedies. — The observations of Collins,^ under antisyphilitic treatment in tabes, equally apply to the advisability of antisyphilitic treatment in paresis. When syphilis is the causative factor neuro-alienists are not agreed as to the impor- tance of specific treatment. Some, following Charcot, steadfastly hold that such treatment is useless, no matter how indifterently the patient may have been treated during the active period of the syphilitic poi- > Treatment of Nervous Diseases, p. 333. 276 TREATMENT. son, providing that the symptom-complex of paresis did not develop within a short time after the syphilitic infection, from two to four years, when the lesion may be properly considered a true syphilitic and not a parasyphilitic one. On the contrary, others, following Erb, recommend an active course of antisyphilitic medication in every case of paresis with a history of syphilis, or even upon the suspicion of a taint, or where this method will speedily clear up any confusion with cerebral syphilis. Berkley ^ inaugurates, at once, inunctions of blue oint- ment, or oleate of mercury, or the hypodermic admin- istration of the bichloride, or the sozoiodolate of mer- cury in salt solution. While his preference is for the mercurial salts, he uses, also, the iodide of potassium in doses gradually increasing to sixty grains or up- wards, thrice daily. In these cases. Osier ^ pre- scribes large doses of the iodide of potassium. Collins believes that the best results can be obtained by the use of mercury by inunction; if this method cannot be carried out then its use hypodermatically. Mer- cury, as specific means, he believes should be given in no half-hearted way. He is accustomed to use from thirty to forty grains of blue ointment rubbed in daily, each application lasting from twenty to thirty minutes and the course continued from five to six weeks. He cautions watchfulness over the condition of the patient's alimentary tract, skin and body weight. Too much care cannot be taken to keep him clean, much in the open air and well fed. Great importance is attached to the maintenance of the body weight; if