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persons, there is no plea made more persistently and more urgently than for something to make them sleep. They want medicines to do wholly what food and rest ought to do mainly, and what medicines only assist in. Children and young persons, overtaxed at school by studying in bad air, grow pale, languid, irritable, and restless, lose appetite and sleep poorly. We know in such cases that food given with blood-enriching tonics, as phosphated elixirs of iron and cinchona, or gentian, or the chloride of iron, with barks, at meals, and malt, either liquid or dry, given with milk on going to bed, will relieve this condition of malnutrition from over-tax much better than what are called "quieting" remedies. We have received into the hospital many young patients under such circumstances, where I have felt that timely medical advice and aid might have met their condition at a stage which would have anticipated and prevented the development of insanity. There are such cases in the hospital now. The same remark applies to children of older growth.

There is one further hint of great importance to the development, growth, and stable health of children. Children or youths at school or at work, who are attacked with acute diseases, should not be returned to the school or the workshop until after complete convalescence; as in cases of fever, measles, and diphtheria, and especially where the nervous symptoms have been more or less pronounced. It is too common to allow such children to go back to school or to work as soon as they are fairly about. The brain, after such disturbance of circulation and nutrition, particularly needs rest. I have seen great evil from neglect of this course in many cases. The children are unable to work and to recuperate at the same time, the general health is lowered, the anæmic state becomes persistent, chorea and hysteria often follow, and the physical development is impeded. Many cases are brought to the asylum, in which the history goes back, through years of more or less delicate health, to neglected care in convalescence from these diseases; and I feel that I can not too strongly impress the importance of this matter.

The early recognition of alteration of character, changes in the way of thinking and acting as manifested in the ordinary

topics of conversation, evidence of distrust and suspicion of others, over-timidity about ordinary business or household affairs, unusual anxiety about children, etc., all are early indications of mental unbalance. They are among the early changes of character, often shadowy and ill-defined, but at the same time distinct enough to be recognized. Just at this point, attention to the physical condition and a frank statement to the person of the necessity of resistance to such drift of thought, are of the highest importance, and, in a vast number of instances, would prevent the development of insanity. Of course, it is assumed that each person must be judged of from his or her own stand-point. What would be cases of worry or anxiety in one person might not be in another; and, therefore, it must be the change observed in each person; i. e., how far he or she has departed from the natural, normal course of feeling, thinking, and acting. Such persons are ill; and it does not do to direct attention only to the morbid drift of thought and say: "Oh, you are nervous; you must throw these things off; take exercise; walk two or three miles every day," etc.

I remember the case of a young lady whose friends called upon a physician in New York, stated her case, and recited certain marked changes in her conduct, habits, etc. She was unnaturally reticent, apprehensive, and at times seemed unable to keep her attention on her studies or ordinary duties. The physician had two or three protracted consultations, and then said: "There is nothing particularly the matter. She needs cheerful society, country life, and long walks," and he advised that she be taken to a place in the country where this would be secured. He gave the friends a long list of written directions (afterward handed to me) for physical exercise consisting very largely of walking, ordered frequent ablutions and plain diet, and assured the friends that they need have no apprehensions about her. Within forty-eight hours, she was received at the asylum in a state of acute mania.

Another instance was that of the daughter of a Congressman residing in Washington, who, after some four months of very active social life, was called upon for some weeks to attend assidu

ously upon a sick member of the family, became sleepless, depressed about her spiritual condition, and reserved, and lost flesh. Her father concluded to take her home, and with his family he stopped on the way in New York, as these manifestations were increasing in intensity, and consulted a physician. He was advised, after several consultations, to return with her to Washington, to re-enter society, to go to places of amusement, to theatres, etc., or, if he went home, to give her all the social life possible, and thus throw off her fancies. On the way home, she became so excitable, and finally maniacal, that he telegraphed from Albany to ascertain if we could receive her into the hospital, and, in twelve hours after leaving New York, she was brought to the asylum, with furious mania.

In such conditions, the serious consideration of the practitioner is demanded to inquire carefully and frankly into the health of the individual; and the causes of the changing mental state will then be found and can be met. Such persons, under the quiet, intelligent assurance of a physician as to their condition, and given to understand that the uncertain mental state which they generally recognize in themselves is dependent upon the condition of bodily health, which can be remedied, will ordinarily assist in their own cure.

I do not feel justified in taking up the time of the Associa tion in presenting cases. I think instances will occur to the minds of practitioners. One thing is important: patients should not be startled with statements which will arouse apprehensions and fears.

Some years ago, a gentleman arrived at Utica, from New York, in the evening, and sent his servant with a note, in which he requested me to come and see him, asking me to reply by the servant. I asked the servant if the gentleman was ill, and he replied: "No, but he seems very uneasy." I called to see him, and found him walking about anxiously. He said, abruptly: "I want you to give me a thorough examination and see what is the matter with me." I did so, and said: "I don't see anything the matter with you; nothing serious; you are probably tired out. A few days' rest, with wine at your meals, and you will get along." I found

he had been quite actively engaged (much more than usual), had lost sleep, had partaken sparingly of food, and was quite fagged out. He then said: "Dr. told me two days ago that I had congestion of the brain, and that I had not come to him an hour too soon. He insisted on my remaining in New York, and then made for me the following prescriptions: First, five grains of bromide of sodium and a drachm of tincture of calumba in water three times a day, for one week; then, five grains of bromide of calcium in two drachms of camphor-water three times a day for a week; thus alternating the remedies. He added: 'If you don't find yourself relieved I shall come and see you.""

I might give a large number of cases where, if in the early stage of change or alteration of character a course had been taken requiring rest, generous nourishment, with milk, milkpunch, a discreet nurse, and the quiet assurance of the physician, no such catastrophe would have ensued.

In this paper I have not desired to do more than to throw out a few hints on the preventive measures which are wholly within the province of every practitioner.

22

EXCISION OF THE KNEE-JOINT INSTEAD OF

AMPUTATION OF THE LIMB IN CERTAIN
DISABLING DEFORMITIES DUE TO THE
POSITION OF THE KNEE.

By STEPHEN SMITH, M. D., of New York County.
Read November 19, 1884.

THE class of cases specially referred to in this paper is illustrated by the following detailed report of cases treated.

CASE I. In 1878, a boy, aged ten years, came under my care, who had walked with a crutch since he was three years old. His special disability resulted from infantile paralysis affecting the left leg which was flexed at the knee at about a right angle. On examination, it was found that this flexion was caused by paralysis of the quadriceps extensor muscle, to such an extent that the flexor muscles (the biceps flexor cruris, and the semimembranosus and semitendinosus muscles) were not counteracted, and hence the leg had gradually been flexed upon the thigh, until it reached and maintained the position above mentioned. The limb was generally atrophied, but its actual length was the same as that of the right leg, as nearly as could be ascertained by measurement in its displaced condition. The boy walked about on the right leg and a crutch on the left side. His parents were very anxious to have him relieved, and they consented to amputation or excision of the knee-joint, if found necessary.

The first operation consisted in division of the tendons of the

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