A general paralytic is at any time liable to congestive or maniacal attacks of short duration, and so is always, potentially, a dangerous person. In the prodromal period the risk is small; in all stages there will, in the majority of cases, be some warning; but in the developed disease the only safe way is to have some responsible person near at hand, both to prevent the patient from doing harm to others and to save him from injuring himself, whether by intent or through not knowing better than to wander off or fall into all sorts of accidents. In many conditions several should be readily available, or else the security of an asylum must be sought.
In the treatment of general paralysis by society the same rule should obtain as in all forms of insanity—that distinct mental disease is presumptive proof of irresponsibility, or at least of limited responsibility; that a diseased mind means lessened intellectual power throughout and diminished ability to choose the right and avoid the wrong; that there are changes in circulation or nutrition, or some unknown condition in the brain, especially in general paralysis, by virtue of which the mental state and power of self-control vary from time to time, and as a result of which a person seeming responsible one day may have been quite irresponsible some previous day.
INSANITY FROM GROSS LESIONS OF THE BRAIN (tumors, new growths of all kinds, exostoses, spicules or portions of depressed bone, embolisms, hemorrhages, wounds, injuries, cysticerci, etc.) is attended with the usual indications of those conditions which may determine diffuse disorders of the brain, giving rise to any of the symptoms of the various psycho-neuroses and cerebro-psychoses. The lowered mental and moral tone after cerebral hemorrhages is a matter of common observation, and after one an individual is rarely observed to be fully himself again.
The PROGNOSIS is very unfavorable. Although there are rare cases of improvement, the tendency is toward profound dementia.
CEREBRAL SYPHILITIC INSANITY comes either under the head of the insanity last described or belongs to the slowly-advancing dementia with final paralysis already referred to under the head of Diagnosis in General Paralysis, and called by some authorities on mental disease pseudo-paralytic dementia from syphilis.
Antisyphilitic treatment is of value in the first class of cases, and although most of the recoveries end in relapses and incurability, the prolonged use of iodide of potassium seems sometimes to effect a permanent cure. It is claimed that similar treatment is followed by the same result in the cases of dementia with paresis, but the weight of authority, and certainly my own experience, are against that statement.
CHRONIC ALCOHOLIC INSANITY depends upon the vascular and other changes due to abuse of alcohol so long continued that the pathological condition has become organic and incurable. It is commonly associated with delusions of suspicion or persecution. It may be a purely moral insanity, with gross beliefs rather than distinctly insane delusions, and it rarely fails to be at least that when the persistent excessive drinking is kept up until the age of beginning dissolution of the brain. It then gives rise to all sorts of embarrassing complications in regard to property, family relations, and wills. Chronic alcoholic insanity may take the form of mild dementia, by virtue of which the patient cannot control himself, but can be easily kept within bounds of reasonable conduct by various degrees of restraint, from the constant presence of a responsible person to the seclusion of an asylum. In well-marked cases this dementia is associated with muscular weakness, tremor, and exhilaration to such an extent as to simulate general paralysis. It is then called by some—especially French—writers pseudo-paralytic dementia from alcohol.
The condition is susceptible of improvement by removal of the cause, alcohol, and by a carefully-regulated life, hydropathic treatment, etc., but complete recoveries cannot be expected.
SECONDARY DELUSIONAL INSANITY is slowly developed from various mental diseases, incurable or uncured, where the progress to marked dementia is slow, by the persistence of delusions in those forms of insanity characterized by delusions. It is chronic and incurable. In melancholia and mania the mental depression and the exaltation and motor excitement disappear to a great extent, and there are left a slowly-advancing dementia, confusion, and expanding delusions, with apathy or with agitation, for which the asylum is the only safe place unless physical weakness makes the patient harmless. It is either a terminal state in which many forms of insanity end, or a stage through which they pass to terminal dementia. It depends upon incurable, and therefore organic, changes in the brain, like all incurable insanity, although those changes are not yet determined exactly. It might be a question whether chronic delusional insanity properly belongs under the head of Organic Mental Diseases, and a similar criticism may be made regarding terminal dementia. But in this paper no definite classification of insanity is attempted, because our knowledge of the subject is still so indefinite, although the several mental diseases are grouped in a certain order for convenience to the reader and the writer; and this order of course approximately follows natural lines.
TERMINAL DEMENTIA is the end to which most of the insanity not resulting in recovery finally comes. The features marking the disease in its early stages for the most part disappear, leaving all the functions of the mind impaired in all degrees up to total extinction—the whole character on a lower plane. It is the disease which to so great an extent crowds the wards of insane asylums and almshouses with the (1) agitated or (2) apathetic chronic insane, the worst of whom are mental and physical wrecks, squatting on floors, uttering an unintelligible jargon, noisy, filthy, without intelligence for the simplest natural wants. Their chief function, under the prevalent methods of construction and management of lunatic hospitals in most places, is to blight with a certain feeling of hopelessness many of the curable insane who are obliged to go for rest and quiet to institutions where the overwhelming majority of the inmates are manifestly and painfully incurable.