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How deplorable the spectacle presented by this young monomaniac, who,
strong robust, full of life, and destined to a brilliant future, at the
age of thirty years, in consequence of some trifling discussions respecting
matters which were to him of some interest, persuades himself that he is
the possessor of an immense fortune, which he inconsiderately spends, and
believes to be an object of desire with all. He purcheses unnecessarily,
and withut reason, every thing that offers; furniture, horses, carriages,
pictures, etc. etc., and yields himself at the same time to all the excesses
of the most fashionable life. The counsels of his relatives and friends
fail to bring him back to the path of moderation in his thoughts, desires,
or conduct; which a little before they admired. becoming excessively susceptible,he
is irritated, and thrown into a transport of passion by the slighest observation.
He refuses all medicine; assuring those around him that he was never so
well or so happy. He was brought to Paris by Doct. K., physician equally
skillful and estimable. 'I commit to your care,' says my confrère,
'a very interesting patient who is but slightly excited, and whom I have
widhdrawn from scenes calculated to augment this excitement, which you
will speedily cure.'
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| What was the outcome in this case? | |
I converse with the patient who speaks to me of his
fortune, his projects of happiness for himself and his friends, of the
numerous acquisitions which he is to make in Paris, etc. etc. After half
an hour's conversation, 'What do you think?' says my learned froend. '
I think that your patient is incurable; that he will not recover, nor survive
a year. Remain in Paris, and you will see, as the malady is making rapid
progress.'
In conversation with the patient, I had remarked
some hesitation in the pronunciation of certain words, and undue readiness
with which he had consented to remain in a private hospital. More extensive
observation enabled ma to obtain a glimpse of certain slight defects of
memory, and a forgetfulness of the projects of the evening previous. I
was struck by the indifference and the air of contentment which tha patient
manifested, though deprived of his liberty, and incapable of gratifying
his caprices. He deferred daily to the morrow, the accomplishemnt of projects,
which at first he wished to execute instantly.
What
was Esquirol's diagnosis?
Complicated dementia...exists in connection
with lypemania, mania, epilepsy, convulsions, sucrvy, and especially paralysis.
Complicated dementia is incurable. Hippocrates has set down as a mortal
sympotm in acute maladies, the complication of delirium with any variety
of convulsions. What the father of medicine has said respecting acute diseases,
is applicable to insanity, and particularly to dementia. The complication
of mental diseases with lesions of motion, resists every curative measure
and leaves no hope of protracted existence. ...In 1805, I first called
attention to this phenomenon, and established by proof, the incurability
of insanity complicated by paralysis. This form of paralysis is often
the sign of chronic inflammation of the meninges, and should not be confounded
with paralysis which is consecutive to cerebral hemorrhages, cancers, tubercles,
and softenings of the brain.
It appears, now with the
first symptoms of delirium, during the period of acuity, so remarkable
at the commencement of almost all forms of insanity; now, it precedes the
delirium; and now, joins
itself in some sort to it. Finally, whatever may be the epoch at which
paralysis appears, its invasion sometimes
takes place without grave phenomena; and sometimes, it is the result
of congestions, cerebral fevers,
epileptiform convulsions etc. At first, it is partial; it then invades
a greater number of muscles and becomes
general. Its progress is regular; it goes on constantly increasing,
while the understanding grows weak. Whatever
may be the character of the delerium, it indicates a speedy transition
from insanity to chronic dementia; It is
rare that insane paralytics live more than from one to three years;
and among them, the strongest and most
robust die most suddenly. Generally, the last moments of life with
these patients are marked by convulsions,
cerebral congestions, visceral phlegmasia, and gangrene, which embraces
all that portion of the body which is
deprived of the power of motion, and upon which its weight reposes.
At the expiration of fifteen days the embarrassment
of the tongue had increased; loss of memory is more frequently made manifest
and before the close of the month, his step is less easy, and he grows
lean, although eating largely. Leeches are repeatedly employed; a seton
is inserted in the neck and valerian is prescribed as well as laxatives,
to prevent constipation.
Nothing succeeded in staying
the progress of the inflamation of the meninges, and consequently that
of the paralysis. At the expiration of three months his ideas were almost
extinct; he no longer remembered any thing; and merely uttered words without
any connection; repeating often, million, horses, château,
carriage,
etc. etc. He conducts like a child; totters in his gait; and sometimes
discharges his urine involuntarily. By slow degrees, he becomes more feeble;
no longer speaks but in a low voice; and never leaves his armchair, unless
he is induced to walk, and sustained beneath both arms. His appetite is
at all times voracious.
At the fifth month, the
patient scarcely articulates, and can no longer be understood. The
dejections are involuntary, although the matters are solid, and the urine
is discharged unconsciously, both day and night. Finally, at the commencement
of the sixth month, he is confined himself to bed; suffered for two days
from epileptiform confulsions, and at the expiration of seven months sunk
from a disease, which, which at its commencement, appeared so trifling
that the experience of a distinguished physician failed to recognize it
[Esquirol,
1845/1965, 435-7].