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INSANITY.

UNDER THE CHARGE OF

J. BATTY TUKE, M.D., Hon. D.Sc.Dub., F.K.C.P.Ed., SUPERINTENDENT OF SAUGHTON HALL ASYLUM ;

AND

JOHN MACPHEESON, M.D., F.R.C.P.Ed., SUPERINTENDENT OK T11E STIRLING DISTRICT ASYLUM.

Tiie Treatment op Mania.

Dr. Magnan {Rev. de PsycliiatJuly 1897) in this article strongly advocates the seclusion of maniacal patients in asylums, at as early a period of the malady as possible.

1. He deprecates all methods of restraint or forcible treatment, and

strongly recommends what he terms the hospital treatment of patients, by placing them in beds in an ordinary ward amongst other patients, and not by themselves in single rooms. In his experience of this form of treatment, he finds that the patients for the first two or three days are noisy, troublesome, and restless. At the end of that time, although still excited, they do not attempt to get out of bed, and if they do so

they are easily induced to go back again. The excitement gradually becomes less during the night, and at the end of a few days the patients usually obtain a few hours of natural sleep. In cases of great excitement it may be necessary to remove the patients from the usual dormitories to single rooms during the night, but the necessity for this nocturnal seclusion usually passes off at the end of a few days. The second part of the treatment consists in the simultaneous administration of pro-

longed warm baths, with bromide of potassium and chloral hydrate. The bath, usually heated to 33? C., is continued from one to five

hours, according to the degree of excitement, and cold may be

applied to the head by using compresses, or by a slender stream

of water, the head being protected by linen cloths. If the patients are too excited to be bathed, damp sheets may be applied to the body, while the feet may be placed in hot water and mustard. These

remedies, the author states, produce a very marked sedative effect, and enable the patient to obtain much needed repose.

2. Bromide of potassium is given in doses of from 3 to 5 grms. at

the evening meal, and two or three hours afterwards it is followed by a dose of from 2 to 3 grms. of chloral hydrate. Given in this manner, the

two drugs act most efficaciously, and their combined action almost always produces sleep. At the end of about ten days, should the nights become better, the administration of the bromide is suspended, and the chloral is only given conditionally, that is to say, if the excitement

becomes worse. The author has always found chloral more efficacious for this purpose than either trional or sulplional. When none of these

drugs give favourable results, he has recourse to laudanum, administered in progressive doses, commencing with fifteen drops a day, and increasing

512 RECENT ADVANCES IN MEDICAL SCIENCE.

the dose until 4, 5, and even 10 and 15 grms. are given per day. Neither morphia, hyoscyamine, nor digitalis has given good results in the author's hands. He has, however, obtained very good effects from a

combination of the liydrochlorate of hyoscine, with cherry-laurel water (the dose given being equal to a milligramme of hyoscine), in temporarily allaying excitement, and in producing several hours of quiet sleep.

3. Dr. Magnan is emphatic on the necessity of carefully watching the patients' general health, especially with regard to food and nourish- ment. He strongly disapproves of the administration of alcohol in any form, for which he substitutes milk, water, lemonade, and various

infusions.

The Significance of Palatal Deformity in Idiots.

Dr. Walter Channing contributes a paper (Journ. Merit. Sc., London, January 1897), with the intention of showing that the emphasis usually laid upon palatal deformity, by authors writing on the subject of degeneration, is misplaced. Out of 1000 idiots, the author found 40'9 per cent, possessed of normal palates. In 11 per cent, the palates approximated the normal so closely as for all practical purposes to make them normal, while in 48*1 per cent, there was distinct

abnormality. Out of 212 normal individuals, the palate was found to be structurally normal in only 22'1 per cent. Assuming that the

statistics presented above are correct, the author arrives at the con-

clusion that not only do we find many slightly deformed palates in

idiots, but also an important percentage of average or fairly good palates. Precisely as in a normal individual a deformed palate may not by itself be a sign of degeneracy, so in the feeble-minded or idiots a palate of average normality is no indication that the individual is not

degenerate. A further fact noticed by the author in the palates of

mentally defective children was that those over 12, even up to 15

years of age, often preserved the infantile character of the palate, so that a large number could be placed side by side with those of normal children below 12 years of age without any apparent difference.

These observations of the palates of young children lead to the con- clusion that at least up to 8 years of age there are in a large proportion of cases no essential differences to be observed between the palates of idiots and of presumably normal children. So-called characteristics of shape and size, which would serve to differentiate the former from the latter, are not sufficiently or definitely marked to be reliable for such a purpose. So far as the idiotic or feeble-minded are concerned, he believes that the deformed palate is only one of an indefinite number of indications of imperfect anatomical development, occurring to a

marked or very slight degree as hereditary and environmental causes may determine.

The Role of Disseminated Multiple Sclerosis in Diseases of the Nervous System.

In this article (Arch, de neurol., Paris, August 1897), Professor

Grasset attempts to establish a uniform etiology for a large section of

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nervous diseases, including bulbar paralysis, locomotor ataxia, progress- ive muscular atrophy, general paralysis, etc., based upon the presence of disseminated multiple sclerosis, affecting not only the nervous

system, but other important internal organs,?heart, kidneys, liver, and blood vessels. Sclerosis he defines as hyperplasia or liyperproduction of connective tissue. The characteristic effect of sclerosis is always the same. It is the substitution of liypertrophied interstitial tissue for

active organic atrophied tissue. It is manifest that here a double pro- cess takes place, equally characteristic. If the hypertrophy of the

connective tissue is primitive, and crowds out the parenchymatous tissue, we have one variety of sclerosis. If, on the other hand, the

parenchymatous atrophy is primitive, and the hypertrophy secondary, we have another variety of sclerosis. Yet in both cases the final

result is the same. Indeed, in the nervous system the two processes proceed side by side, and are seen associated in the same individual. In combined forms of tabes there often coexist a diffuse myelitis and a systematised myelitis. Even in ordinary tabes, certain lesions, such as those of the meninges, are not strictly systematised.

Applying his theory to the relations between locomotor ataxia and general paralysis, he remarks that along with tabes there frequently coexist in the same individual numerous pathological and clinical

symptoms, which correspond Avith other foci of disseminated sclerosis

in the nervous system. The relation between tabes and general paralysis has long been recognised, but even now, when psychical symptoms supervene in a tabetic subject, or locomotor ataxia follows general paralysis, it is referred to as a complication, as an extension of the disease, or the original diagnosis is altered. The true interpretation of these facts appears to be found in admitting that both in tabes and general paralysis there exist two groups of lesions, quite distinct, united only by common causes, and by the same general disease in the same individual. This common cause of the two diseases is disseminated

sclerosis, for sclerosis plays a real and important role in the production of general paralysis.

The author's opinion is that poisons and infections are the great causes of the production of multiple disseminated sclerosis. At the

head of these infections, so far as tabes is concerned, he places syphilis. He is, however, far from agreeing with Marie that the syphilitic poison is the direct and only cause of all cases of tabes. Besides poisons and

infections, heredity plays an important part in the production of

disseminated sclerosis. He also credits hereditary or acquired arthritism, chronic alcoholism, tobacco, and senility with exercising a slow but

durable influence in the production of this disease.

Idiopathic Internal Hydrocephalus in the Adult.

Dr. Martin Prince (Journ. Nerv. and Ment. Dis., 1ST. Y., August 1897) records five cases illustrative of this affection. In two of them

the result of post-mortem examination is recorded. The funda-

mental conception regarding the affection, in the author's view, is

that it consists in an ependymitis, giving rise to a serous effusion

into the ventricles of the brain. The causes, so far as known,

514 RECENT ADVANCES IN MEDICAL SCIENCE.

are injury to the head, mental overstrain, alcoholism, disease of the middle ear, and acute infectious diseases. The affection may be either acute or chronic. The chronic cases present symptoms so closely resem- bling tumour that they are usually diagnosed as such. The symptoms, as in other brain affections, are general and local, and depend largely on increase of pressure. The general symptoms are headache, vomiting, fever, stupor, delirium, optic neuritis, and convulsions. The local

symptoms are usually paralysis of the cranial nerves, especially exophthalmos, pain and rigidity in the neck and extremities, and hyper- esthesia. The acute form may, after a course of some weeks, end in either complete recovery or death, or become chronic. The chronic form may pursue a varied course, with remissions and acute exacerba-

tions, continuing for years, and ending finally in recovery or in death. With regard to diagnosis, great stress is laid upon the variation in the intensity of the symptoms from day to day. These remissions and intermissions in the chronic cases must be largely relied upon to distinguish them from cases of brain tumour. The pathological signs are for the most part limited to accumulation in the ventricles of clear fluid, which does not materially differ from normal serum. The ventricles may be

abnormally distended, and the pressure so increased that the convolu- tions become flattened, and the sulci obliterated in appearance. The

changes in the ependyma are limited to hyperemia in the acute stages, and to some slight thickening in the texture (described as smooth, velvety, granular, or sodden) in the more chronic stages. The pia may be also hyperaemic, and present somewhat the same appearances. Quoting Quincke, the author likens the affection to an angio-neurotic acute oedema of the skin, which would render intelligible the sudden development and variation in the pressure symptoms observed. It is

not quite clear to the author's mind that the effusion can be regarded as of an inflammatory character. As to treatment, the author believes with Quincke that recovery may be promoted by the use of mercury. He mentions lumbar puncture as a feasible remedy, but in cases

pursuing an unfavourable course, and where a fatal issue seems imminent, he is inclined to advise tapping of the ventricles.