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With the almost universal antecedent of syphilis, it might naturally be supposed that a trial of specific medication would be in order, at least in the cases where the specific disease is of comparatively recent date. Some authorities mention this only to condemn it, but there are many cases in which, according to our experience, a cautious trial of specific medication with iodids may do no harm, and there are some in which it has seemed to be of some benefit. If it is employed, it ought to be carefully watched, and stopped if it shows the least sign of disagreeing with the patient's general health, or causing any aggravation of the paretic symptoms. Not very much is to be expected from its use in any event, even in those cases in which tertiary symptoms are still apparent. Considerable benefit has been claimed in times past from active counterirritation, even blistering the scalp to the extent of denuding and corroding the skull, but such measures are little used at the present time. Very recently Dr. G. W. Foster has reported a remarkable success with hydrotherapy in paresis; in six out of twenty-one cases thus treated a complete arrest of the disease was obtained for periods ranging from some months to three years and over. From his testimony the results of this treatment are the most encouraging of any that have been tried, and full details, as yet unpublished, are to be desired. Hydrotherapy in other hands has not always been so successful. The prolonged warm bath for half an hour to an hour, with perhaps cold applications to the head, is useful sometimes in the excited stage in cases not too far advanced, but shower-baths, cold baths, etc., are in our experience generally contraindicated.

The paretic in the active progressive stages of his disease is always best treated in an asylum or its equivalent. During the remissions it may be possible for him to be released temporarily, but he should al

ways be under medical oversight. The excitement of outside life, the lack of regulation of habits, and, it may be, renewal of excesses, are all likely to bring on a relapse, and render paroling or furloughing this class of patients somewhat of a perilous experiment.

The symptoms that may occur from time to time of excitement, etc., call for appropriate treatment-sedatives, hypnotics, etc. In the congestive attack it may occasionally be useful to employ brisk purgatives and local applications to relieve the congestion, but abstraction of blood is undesirable. The condition of the bowels is always to be watched; any constipated state is likely to aggravate the disorder, and, on the other hand, paretics are occasionally carried off suddenly by choleraic-appearing diarrhea attacks. In the advanced stages when the patient is bedridden and untidy, constant care should be exercised to prevent bed-sores, which will sometimes, however, occur in spite of the most careful treatment. Occasionally they seem to be directly connected with cerebral or spinal lesions, and form rapidly appearing and extensive sloughs over the sacrum or the buttocks, but the more common form is that due to the general deteriorated trophic functions, occurring at any point subjected to pressure. Whichever way they occur, they form a troublesome complication, and one that helps materially to the final fatal termination. The utmost cleanliness, bathing with diluted alcohol, frequent changes of position, water or air cushions or mattresses, are at best only palliative measures in these cases. Attention should be paid also in paretic cases to the slightest suppurative inflammation, as a general pyemia or septicemia is often easily set up. On the other hand, in the second stage there is frequently observed an especially marked readiness of repair of injuries, but this is rarely, if ever, the case in the final stages of the disorder.

In closing the subject of paresis, we may recapitu

late, at the risk of some repetition, the varieties that have been remarked in its symptoms and progress. The typical form with excitement and exalted delusions has been sufficiently described; so also the depressed and hypochondriacal form. The latter occurs, according to Kraepelin's estimate, in about 27% of all cases; we should estimate it at rather a less figure in our experience. If, however, the typical demented type is here included, a considerably higher percentage may be allowed. In this the dementia predominates, and the delusions and other active intellectual aberrations may be altogether absent. According to a recent writer (Bremer), this type is becoming more and more frequent of late years, and tends to replace the typical form. There are occasionally occurring cases in which the mental symptoms of the early stages are wanting, and the dementia comes on at once after an apoplectic or convulsive attack. There are also cases of paresis without these attacks of either kind, and others in which they are so frequent as to dominate the syndrome, and mental or emotional symptoms are almost completely lacking during the entire course, or so slight as to readily pass unnoticed. In other cases still, the earliest symptoms are spinal, and the disorder may be diagnosed as tabes, till these disappear and give place to the more typical physical symptoms of paresis. Cases like this are rather rare, but we have observed several such. In other cases the ataxic symptoms continue, though more or less masked by the advancing paresis. Still another form may appear quickly, and take on the symptoms of acute delirium, carrying the patient off in a few days or weeks-the so-called galloping paresis. Then we may mention the juvenile paresis, appearing generally at or near puberty in victims of hereditary syphilis. In these the symptoms may be more or less typical, but generally of the demented rather than the active or exalted type.

Lastly, we have the circular type, in which the form of the peculiar degenerative cyclic insanity is superimposed on the paresis.

The percentages of the different forms are thus given by Kraepelin: The agitated form, 11%; the demented, 40%; the expansive type, 15 to 16%; the depressive type, 27%. The other types are exceptional. In our experience we should give certainly a larger percentage of the expansive type as existing among paretics a few years ago, and a very much smaller one for the depressive type.

It must be remembered that the symptoms and the character of the delusions are largely influenced by the natural bent of the patient, and this is also true to a large extent with the type of the disease. Depressed forms of mental disorder seem to increase with civilization, and paresis falls probably in this into the general order of things.

Another notable fact is the increase of paresis in women, which is more marked in Europe than in this country. Here the ratio is still near the old markone woman to five or six male paretics; but the number of the former is appreciably increasing here also. It has been often observed that this increase abroad is chiefly amongst the lower classes, and in the large cities, and that a well-to-do female paretic is a rarity. In this country this is also true, to a certain extent, but women in good or fair condition in life, and of good education, furnish an appreciable proportion, and the disorder cannot be said to be exactly rare or exceptional amongst them.

CHAPTER XIV.

ORGANIC INSANITY.

ORGANIC dementia, as it is understood in our classification, includes those conditions of mental impairment without active insane delusions or active symptoms of either depression or exaltation, following gross lesions or disease of the brain, and including also a certain class of cases occurring in advanced life where many of the symptoms strongly suggest paretic dementia as it occurs in younger individuals. We include these because this appears to be the best place for them, and because they are etiologically distinct, in our opinion, from true cases of paresis. The usual effects of brain lesions beyond the merely temporary ones are a certain degree of mental enfeeblement or impairment, though in many cases this is so slight as to practically be a negligible quantity. An ordinary apoplectic attack may be recovered from so completely that no trace is apparent of its effect upon the mind. This is especially true of many cases of hemorrhages or embolism in the basal portion of the brain, involving simply the functions of some of the motor tracts. Repeated attacks, however, of this kind are apt to show their effects, and very extensive lesions may be serious in the mental involvement produced from the very first. Lesions in other portions of the brain affect the mind according to the organs or regions involved, and also in accordance with their extent. The mind may be a blank at once from the time of the injury, as in cases where a cerebral traumatism has completely destroyed memory and consciousness of the past life, which are subsequently restored by the trephining out

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