CHAPTER XVIII. TREATMENT. (Part 2)

this cannot be done the mercury should be stopped at once. After the mercury treatment has been sus- pended, the patient should receive a vigorous tonic plan of treatment for several months. > Mental Diseases, p. 195. 'Practice of Medicine, 3d ed., p. 964. MtJ>3CAl- TRRATMKXT* ^77 Tbt ainiar AETie-es witi Collins that nothing Js to be expected from ti>e administration of mercury, be h bv the mo-th, innDctions, or hA-podeimatically, in cases of genuine paresis in which no s'philitic mani* testations are present but that harm even may arise fix>m such a course. On the other hand, iodide of potassium, given in small doses and for a long time, especially in conjunction with measures that improve the nutrition and husband the ene^g^\ is one of the most valuable drugs to delay the decay of the pri* marv neuron. Electricity. — Either static, constant or induced, in the hand of some practitioners, who are skilled in its application, is highly extolled, especially in the pro- dromal stage. Combined as it is apt to be with mas- sage and other devises employed in asthenic nervous conditions it has often been attended with good re- sults. The head and spine are the regions to be treated. Hydrotherapy. — Douches, the warm bath with cold to the head, wet pack and other forms of application of water cure have been very useful in the hands of many in the treatment of the initial period ; and, also, in the later stages this form of treatment has at times brought about marked amelioration of the symptoms. In the Government Hospital' at Washington, as an in- stance, this plan of treatment was instituted a few years ago and the physicians speak most enthusias- tically of the results. For details in the application of electricity, hydrotherapy, massage and rest treatment the student is referred to the well-known works on nervous diseases. Trephining. — Although of occasional value, sur){i« cal measures have proved unsatisfactory. 'iVephininfj has been practiced chiefly, over the parietal region, * Fortjr-iimt AiiiiumI Report, \, \U%, 30 278 TREATMENT. both in this country and abroad. The operation was originally proposed on the supposition that in paresis there was present an increased intracranial pressure. Treatment of Special Symptoms. — In the treatment of the special symptoms the same general principles must be adopted that are found to be efficacious in the relief of the same symptoms, in other forms of mental disease. Mental Excitement. — Sankey recommends the combination of digitalis and opium, as advised by M. Dumesnil. He gives it in the proportion of one drachm of the tincture of opium (Br.) to ten minims of the tincture of digitalis, every four hours, until the patient becomes more tranquil or sleeps. Peterson resorts to hyoscin, hyoscyamin, or duboisin (gr. y^^ ^o gr- "At)) hypodermically, in periods of maniacal excitement. Dercum speaks highly of antipyrine (gr. X to gr. xx), every four hours. The bromides, chloral, sulphonal and trional, by others, are given separately or combined, and paraldehyde for the same purpose, to induce quiet and sleep. The use of the hot bath, with cold to the head, followed by isola- tion, are good tranquilizing agents, as well as the wet pack. Insomnia^ — In the earlier stages of paresis, the patient often suffers acutely from sleeplessness, which serves to aggravate the other nervous symptoms. The remedies suggested in the period of mental ex- citement may all be of service in insomnia. Paralde- hyde, in doses of twenty to thirty minims, may be given at bed time, or double this amount suspended in thin mucilage, administered by the bowel. As Stearns has said, there is less objection by paretics to this drug, on account of taste, than by other classes of invalids. Some alienists keep to the use of chloral TREATMENT OP SPECIAL SYMPTOMS. 279 in preference to the newer remedies. A combination of equal parts of trional and sulphonal answers well as a hypnotic in many instances. The rapidly induced effects of the former are supplemented by the less transient action of the latter drug. These two last- named drugs are not very poisonous in single over- dose, but there is a variety of chronic poisoning b}' them that may be even more serious, brought about by too long duration of their use. The symptoms are an obstinate constipation, diminished quantity of urine and hematoporphyrinuria. If treatment be prolonged, one should be on his guard for the toxic symptoms. Constipation of marked obstinacy with scanty dark red urine, should at once excite suspicion. Chloretone has not passed the stage of experimenta- tion, but already its unfavorable record as a depres- sant of the heart raises a danger signal to its pro- miscuous use. Epileptiform Seizures. — Many agencies have been suggested for the relief of these attacks. Setons and vesicants to the nape of the neck, painting the neck with iodine, and trephining have accomplished but little. The continuous use of the bromides for long periods of time is, perhaps, the best treatment to ward off threatened attacks, giving attention, in the mean- time, to the general condition of the patient. In status epilepticus, rectal injections of chloral in starch water are recommended. The seizures may be so marked as to require the inhalation of chloroform. The bowels and bladder should be evacuated, the lower bowel by enemata. A drop of croton oil on the tongue, if other purgatives cannot be given, may relieve the cerebral congestion by purgation. Apoplectiform Seizures. — In this condition the requirements are, the elevation of the head, the use of free purgation, the application of cold to the 28o TREATMENT. head, with or without a prolonged warm bath. The alkaline bromides and ergot are recommended in full doses. In suitable cases, when the cerebral congestion is marked, leeching, blood-letting by venesection or cup, calomel, digitalis, camphor enemata have all been used. Hot mustard foot baths seem frequently to arrest an attack. Bed-sores. — In the last stages of paresis much care must be taken to prevent the forming of bed-sores. Perfect cleanliness should be enforced; the use of a water bed, with frequent changes of position, and with buffers of some soft antiseptic material over the bony protuberances, is indicated. The skin may be hardened by white of egg and spirits, or by a strong solution of tannin, or a strong solution of sulphate of zinc. If sores form, despite every precaution, they should be carefully treated and watched. Many of these sores are really trophic in character and not due to pressure at all. This is shown by the fact that they appear at points where no pressure has been exerted. Hughes recommends a novel plan of treatment. He orders the sore washed with warm water and castile soap, and then thoroughly rinsed. A liquid preparation of beef bovinine is poured over the sur- face of the ulcer and the surface is saturated by using pledgets of lint. The ulcer is carefully covered, as in a surgical dressing. Granulations appear gradually after this treatment, followed by an epithelial cover- ing. This treatment is effective, for the tissue thus formed is not less resistant than the neighboring skin. Terminal Symptoms. — Life in the open air is ad- visable, as long as it can be continued; as soon as the patient is not able to walk alone he should be given assistance; when this assistance no longer avails, a reclining chair should be used, and thence by stages, TREATMENT OF SPECIAL SYMPTOMS. 28 1 he must go to the constant use of an air or water bed. At this period an abundant and nourishing diet should be used, but it must be administered with care; the paretic is apt to bolt his food and hence is frequently in danger of choking. There is danger, too, of the inhalation of food and of resulting lobular pneumonia. In cases of dysphagia it may be neces- sary to use the nasal tube in giving food; in these, and in very demented patients, it is sometimes im- perative, for brief periods, to administer peptonized food by the rectum. Perfect hygiene is of the utmost'importance. Reg- ular bathing must be continued and a constant vigilance for bed-sores be maintained. At this stage when the sphincters are paralyzed, or at best react sluggishly, cleanliness is difficult to secure but is absolutely necessary. Excreta should be removed promptly and every precaution taken to keep the skin free from irritation. The bowels must be kept open and often comparative regularity of action can be secured by using, at stated times, a simple enema. Gentle massage also may be used to secure regularity of the bowels. In cases of diarrhea, often troublesome in the last stages of paresis, the matter of cleanliness becomes a great tax, but it must be maintained with most as- siduous care, and the diarrhea must be given the usual treatment. Catheterization should be avoided, as long as it is possible to produce urination by other means. The patient must be encouraged to evacuate his bladder by his own efforts, and to complete the evacuation, gentle ^ manual pressure may be used ; unless this is done the decomposition of the residual urine quickly sets up cystitis. ' Be sure the pressure is genUe, for too great force may result in rupture of the bladder. 282 TREATMENT. By such constant and faithful care, the life of the patient may continue for months, in a weak and bed- ridden, but still comparatively painless condition. INDEX. ABSCESS. 66, 150, 233, 235 ^ Acute mania with delusions, 178 Agapoff, 256 Age of occurrence, 204 Amenorrhea, 33 Amnesia, 27-29, 30, 35, no Analgesia of ulnar nerve, 146 Anesthesia, local, 33, 62 Angiolella, 214, 263, 283 Anglade, 193 Anglo-Saxons, paresis in, 210 Anxiety as a cause, 321 Antisjrphilitic remedies, 275 Aphasia, 117, 118 Aphonia, 119, 132, 146 Apoplectiform seizures, treatment of, 279 attacks, 34, 58, 129 Apoplexy, 177 . Appetite, voracious, 55 Argyll-Robertson pupil, 93, 125, 139, 148 Arson, act of, in Arthropathy of knee joints, 151 Articulation, impaired, 33, 45, 56, 65, Bianchi, 124 Bigamy, 40 Bladder, rupture, 281 trouble in paresis, 169 Blandford, 35, 77, 83, 88, 181, 333, 237- 239, 240 Blood changes in, 151, 164 sweating, 147 -vessels of brain, pathology of. Body nutrition, 364 Bones, 158, 160 Bonnet, 193 Brain, pathology of, 246 macroscopic, 346 microscopic, 351 in acute cases, 347 in chronic cases, 348 Briscoe, 339 Bronchitis, 86 Brush, 338 Bucknill, 50, 57 Bucknill & Tuke, 50, 315, 317, 333, 233 Burr, C. B., 158, 160, 336 117 Atrophy, optic, 26, 96, 139, 140, 141, ' PALMEIL, 19, 23, 75 i95 prog, muscular, 150 Auto-intoxication, 214, 263, 273 BAILLARGER, 20, 75, 76 Baker, J., in Bacterial infection, 214, 263, 273 Ball, 21 Ballet, 32, 259 Bannister, 193, 204 Bayle, 19, 41 ^ Campbell, Alfred, 360 Clark, 34, 38, 43, 72, 78, 85, 92,96, 115, 132, 135, 198 Catheterization, 381 Carbuncles, 233 Causes, 17, 1S7 (see Etiology) Cephalalgia, 175 Cerebellum, pathology of, 349 Cerebral seizures, 58,64, 137,129,171 Chapin, 187 Bed-sores, 65, 72, 100, 150, 157, 241 ' Character, change of, 38, 31, 34 treatment of, 280 | Charcot, 93, 105, 193, 375 Bell, Luther, 31 ! Children of paretics, 189 Berkley, 35,62,80, iii, 112, 188, 193, \ Christian, 138, 318 348, 361 Bettencourt-Rodrigues, 134 Choreaand paresis, 238 Chronic alcoholic insanity, 173 283 284 INDEX. Circular form, 82 typical cases of ( Blandf ord) , 82 (Campbell-Clark), 84 (Magnan), 83 (Savage), 83 Classes, higher and lower, 211 Cla8si6cation of varieties, 73 ■Climacteric, influence of, 106 Clouston, 24, 47, 53, 61, 67, 85, 86, 9^' 95» 97. 124 »34» 136, 140* 146* 147, 158, 161, 189, 218, 224. 237, 2^8 Collins, 275 Commencement, mode of, 22 Congestion of optic discs, 142 Congestive attacks, 58, 67 Conjugal general paresis, 107 Contractures, 26, 65, 69, 72, 100, 102, 107, 139, i97» 214 Cortex, pathology of, 248 Cranium, pathoTogv of, 246 Curability, probabfe future, 273 Cystitis, chronic, 167 DAWSON, 142, 148 Deafness, 143, 146, 217 Decortication, 247, 250 Defects of speech, 33,* 45, 5765, 117 Definition of paresis, 22 Deglutition, impaired, 66, 67, 90 Delaye, 17, 19 Delusions of grandeur, 25, 38, 41, 47, 49» 50. 59» 62, 68, 70, 71/207, 227 of persecution, 83. 142 Dementia, simple progressive, 94 Dcrcum. 60, 194, 213, 215, 237, 259 Developmental paresis, 93, 97-106 De Boismont, 30 Diet, 272 Deiters cells, 253 Differential diagnosis, 172 acute mania with delusions, 17S apoplexy, 177 chronic alcoholic insanitv, 173 disseminated sclerosis, i^ epilepsy, 177 lead poison, iSo paralysis agitans, 181 paralytic insanity, 175 senile insanity, 179 syphilitic insanity, 174 Diagnosis, tabes dorsalis, 180 typical cases of diagno8is( Bland - ford), 181 (Folsom), 182, 185 (Tomlinson), 183 Digestive disorders, 33 Discovery, date of, 18 Disseminated sclerosis, 180 Double form, 82 Doutrebente, 188 Down, 91 Dual theory of paresis, 17, 20 Dunn, E. L., 102 Dura, pathology of, 246 Duration, 236 tvpical cases (Brush and Sink- ler),238 (Blandf ord), 239 (Briscoe 1, 239 ( Fisher, E.D.), 237 (Journal of Mental Science), 239 (Lapointe), 238 Dysmenorrhea, 33 CARLY life, paresis in, 93, 97-106 *-^ Edema of lungs, 241 Electricity, 277 Emaciation, 64, 66, 70, 72, 100, 365 Embolism, 242 Epilepspr, 177, 218 Epileptiform attacks, 34, 40, 58, 62, 7o» 72, 83, 90, 95, 133, 196, 200 treatment of, 279 Erb, 276 Erysipelas, 233, 242 Esquirol, 19 Etiology, 187 age, 204 typical cases (Savage), 206 (Tomlinson), 206 epilepsy, 218 typical cases of (Chris- tian I, 218 (Sankey), 219 (Workman), 218 excesses, 212 heredity, 187 typical cases of (Charcot ), 191 (Clouston & Sav- age), 189 (Grannelli), 193 (Hotchkis), 190 INDEX. 285 Etiology, heredity, typical cases of (Mott), 191 (Muller), 192 ( Revue de Psy- cho logie), 190 (Wilson, G. R.), 189, 190 injury to the head, 314 theory of Dercum, 215 typical cases of (Bucknill &Tuke),3i5, 217 (Clouston), 217 (Mickle), 216 (Neff), 316 fRayner), 215 (Sankev), 216 intellectual overwork, 221 typical cases of (Sankey), 222, 223 (Savage), 221 physical overwork and strain, 220 race and social influences, 309 table by Spitzka, 210 typical case (Work- man), 213 sex, 201 ratio of liability, 201 table by Regis, 201 typical cases (Bannister), 204 (Marr), 204 fMiddlemass), 302 (Sankey), 203 syphilis, 193 statistics, by Bannister, 193 by Berkley, 193 by Graf, 193 by Houghberg, 193 by Kraepelin, 193 by Lewis, 193 by Mendel, 193 by Peterson, 193 typical cases of (Campbell Clark), 198 fFolsom), 198 (Norman), 195, 199 (Savage), 195, 197 (Von Rad), 197 temperament, 200 typical case (Savage), 102 toxic agents, 214 theory of Angiolella, 21^ typical cases (Stearns), 313 (Wiglesworth), 314 Exaltation, 30, 31, 35, 42, 50, 53, 53»63 Exhaustion, 64 Exposure to cold causing paresis, 330 Excesses, 3I3 Eye symptoms, 137 FACIAX. expression, 46, 57, 60, 96, 116, 200 Farrar, Reginald, 17 Fatigue, early, 34 Finnegan, 143 First stage (second period), 41 mental symptoms of, 41 hypochondriacal, 43 maniacal excitement, 43 melancholia, 43 physical symptoms of, 44 defects of speech, 45 facial expression, 46 pupillary anomalies, 45 tremor, 45, 46 typical cases of (Bucknill andTuke), So (Clouston), 47, 53 (Fox), 48 ( Hammond) , 50, 54 (Sankey), 49 Fisher, E. D., 37, 96, 338 F'lechsig, 359 Food, 373, 381 Folsom, 34, 36, 37, 40, 73, 79, 108, 109, 183, 183, 185, 188, 198 Fournier, 194 Foville, 162 Fox, 48, 155 Fracture of bones, 159, 160 Froelich, 161 PAIT, 40, 46, 48, 58, 61, 65, 66, 81, ^ 103, I30, 127, 143 Galloping form, 80 Gangrene of lip, i ^5 Gastric crisis, 33, S5 Geil, 259 General paresis following ordinary insanity, 79, 224 following paranoia, 79 Georget, 19 Germans, paresis in, 210 Giannone, 146 Grannelli, 193 Gray matter, pathology of, 249 Griesinger, 34 286 INDEX. Guislain, 314 { Kraepelin, 193 Gun, firing of, exciting cause, 217 1 Krafft-Ebing, 32, 188 UALLUCINATIONS, 73, 85. 90, ^ 114, 131, 217 Hair, 150 Hammond, 29, 40, 50, 54, 63 Handwriting, 119 Haslam, 18 Headache, 33, 34, 128 Hebrews, paresis in, 3 10 Heart, patholoej of, 265 ' Hematoma aur 18, 161, 195 Hemiplegia, 38, 72, 05, 133, 209 Heredity, 82, 106, 187, 267 Higher and lower classes, 211 i Hirschl, 205 I History of paresis, 18 Hoch, Aug., 104 Hoche, 259 Hoestermann, 79 Homicidal impulse, 43, 61, 198, 208 Hotchkis, 190 Houshberg, 194 Hughes, D. £., 79, 280 Hurd, H. M., 33, 233 Hydrotherapy, 271, 277 Hypochondria, 43) 61 Hypothetical case in prodromal stage (Sankev), 24 Hysteroid attacks, 129 INJURY to the head, 214 ^ ** Insane ear," 161 Incontinence of urine, 169 Insomnia, 32, 47, 90, 145 treatment of, 278 Intellectual overwork, 221 Irish, paresis in, 210 Irritability, a symptom, 30, 34, 37-39, 43»6i f ELLIFFE, 81 J Joffray, 93, 190, 259 Joy, excessive, a cause, 222 Juvenile paresis, 93, 97-106 in sisters, 97, 102 I/ATATONIC symptoms, 128, 217 ^ Kidneys, pathology of, 266 Kiernan,2i4 Klippel & Servaux, 170 Knapp, 141 Knee-jerk, relative frequency, 125 T ANGDON, 166 ^ Lapointe, 238 Lateral columns, implication of, 89 LfCad poison, 180 ** Leather-coated jack," 159 Lemoine, 1S8 Lewin, 193 Lewis, Bevan, 27, 29, 30, 31, 74, 88, 122, 127, 133, 135, 137, 164, 251, 253. 355, 258, 261 Liver, pathology of, 265 Lloyd, J. H., 153 Locomotor ataxia, 90, 91 Lunes, pathology of, 265 Lunier, 20, 76, 188 lU ABILLE, 162 ^^' Macleod, 165 Macpherson, 64, 146, 151 Magnan, 84, 190 Malaria, paresis mistaken for, 109 Maniacal excitement/ 43, 48, 278 Manner of development, 18 Marr, 204 Marie, 228 Marinesco, 256 Massage, 271 Masturbation, 114 Medico-legal aspect, 30, 44 Medulla, pathology of, 249 Meeson, 170 Melancholic form, 85 Medical treatment, 273 Mendel, 193, 218 Menses, alteration in, 106 Mental excitement, treatment of, 278 shock, 221 symptoms of general paresis, symptoms of prodromal stage, 27 of first stage, 41 second stag^, 55 of third stage, 64 Meynert, 78, 270 Mickle, 24, 77, 114, 125, 146, 165, 193»205, 211, 213, 215, 216, 221, 224, 248, 249, 251 Middlemass, 106, 109, 203, 325 Mills, 89, 259 Migraine, 146 INDEX. 287 Mode of commencement, 22 Moral perversion,