Due To Cerebral-Arterial Sclerosis And Its Treatment
Dr. T.D Rana, DPM, Ex Resident Psychiatrist, Warran State Hospital,
Warran, Pa, U.S.A
Paper before : 9th Gujarat & Saurashtra Provincial Medical Conference, Navsari, 1956
During my stay in U S A, in 1953-54, I had good opportunity to study Ch. Brain Syndrome associatedCerebral Sclerosis which amounts to about 20% of the population in Mental Hospital. Because of the Social and Cultural demands, most of the elderly in India suffering from such syndrome are kept in home rather than in Mental Hospital. As the general span of life is short in comparison to U.S. there can be such high percentage of sufferers in India.
This paper is based on my observation on twelve cases of psychosis due to cerebral arterial sclerosis. Though this number is too small, rather negligible for description and discussions this attempt is just made to create interest among the general practitioners who are likely to come across such cases and from whose observations we are likely to collect more data on the efficacy of the treatments. With a view to help them diagnosis. I have described in details the pathology and the symptomatology.
PATHOLOGY: The term arteriosclerosismay still be used in a genetic sense applied to a group of vascular disease characterized morphologically by hardening of the vessel wall. It does, however, place under emphasis upon the hardening aspect of the changes that occur with age in the walls of blood vessels. It is now known that the hardening phase is a relatively benign process which produces little, if any, interference with flow of blood. On the other hand, the process known to the pathologist as atherosclerosis is vastly more serious since it is characterized not so much by hardening of the vessel wall as by the narrowing or obliteration of the lumen. It is an occlusive disease that affects the nutrient vessel of the brain, heart or kidney and by progressively choking off the flow of blood leads to functional alteration and even to disability or death. When, therefore, the term arteriosclerosis is used it should be borne in mind that the real nature of the pathological vascular process is an atherosclerosis with its distinctive morphological feature of stainable lipid within the atheromatous lesions.
SYMPTOMS : The memory failure is a capricious one, the same name being recalled at one time and forgotten at another.
1. The memory defect becomes more general and gradually extends from recent to remote events. Sometimes the gaps in memory are supplied by confabulations. Emotional instability is also an early symptom; the patient's eyes readily fill with tears, and he laughs without sufficient cause. Irritability increases, with outbursts of morbid anger, often to the patient's distress. As the condition advances, suspicion arises which may develop into delusions of jealousy. Periods of clouding of consciousness are not infrequent, and in these partially disoriented states with their poorly connected thinking, episodes of violence, e.g. against the patient's wife, readily occur. Restlessness, both by day and night, and sleeplessness are common. States of morbid apprehension may sometimes culminate in panic, usually with clouding of consciousness, in which the patient believes himself about to meet some terrible fate. The personality is fairly well preserved, but with the increase in the mental symptoms , there is a gradual deterioration in the patient's appearance. He becomes slovenly, allows his clothes to become stained, and has to be reminded to wash. Insight is usually good at first, the patient being distressed by his condition, but it gradually fades.
In the case of sclerosis of the large cerebral vessels the first gross symptom may be an apoplectic stroke, aphasic attack or other focal disturbance. Vertical headaches, worse in the morning, vertigo, short periods of confusion, and fleeting loss of power in arm or leg, or momentary aphasias or apraxia usually give warning of subsequent more serious focal lesions. The gait is wide base, short step and spastic. Coarse tremors may appear, and the patient may finally experience much difficulty in feeding himself. Cardio-vascular disease in the form of cardiac hypertrophy, coronary sclerosis or chronic valvular disease is common. Numerous paralytic lesions appear, evidence of focal destruction of nervous tissue by occlusion or by rupture of a vessel of considerable size. Upper motor neuron paralyses and various aphasias and apraxia are most frequent, Paraphasia or confusion of words may occur. Deterioration and dementia are hastened by these focal lesions especially by those that result in serious speech disturbances. Certain intellectual functions may be much impaired while others remain comparatively intact. Epileptic form of attacks either Jacksonian or general, may occur due to (some believe) temporary anemia or edema.
TREATMENT : Recently much progress has been made in the treatment of psychotic reaction in the aged. Previously treatment of psychotic reaction in the aged was none, for it was believed that senile organic changes, both progressive and irreversible were the sole causes of mental symptoms. Recent studies have shown that there is no direct co-relation between the intensity of mental symptoms andseverity of pathological changes.
The significance of anoxia disease, particularly in elderly arterio-sclerosis patients is now recognized. As brain is particularly sensitive to oxygen deficiency, anoxemia leads to impairment of normal-brain functions. A direct relationship between the degree of anoxemia and the extent of mental disturbances can be demonstrated by oxygen metabolism at capillary level of function.
Many drugs like Tolozoline (Prescoline), Steroid hormones, Dl-ampehtamine Sulfite (De- xidrine), Caffeine, and ephedrine, various vitamins and proteins were tried by different people with varied results. But metrozol and nicotinic acid are widely used nowadays over the continent and so we will discuss these two drugs and an Indian Herbal drug that I have tried in detail.
During past few years the analeptic Metrazol has been the subject of several clinical studies of fatigue and in the field of geriatric. Metrazol has been used in the treatment of senile confusion, and psychosis and other depressed states in which the normal physiologic oxygen balance is impaired and anoxemia is a primary factor to be considered in diagnosis and treatment.
Metrazol exerts a stimulating action on the cerebral centers and particularly on the respiratory and vasomotor centers although all parts of the cerebral spinal axis are affected to some degree.
On the basis of these facts one might expect that Metrazol by stimulating the respiratory center in the aged would improve pulmonary ventilation and indirectly the circulation and so help to overcome the anoxia frequently present in the aged, the depressed and the fatigued. At the same time the analeptic action of the drug and its ability to increase nerve impulse transmission should act as a general tonic so that the patient might well have an increased sense of wellbeing, be less depressed and perhaps also less confused.
After the successful use of nicotinic acid in relieving mental symptoms of pellagra, this drug soon was applied in the treatment of a number of psychiatric syndromes, particularly organic psychosis of varied etiology. Nicotinicacid is of value in the treatment of organic psychosis attributed to cerebral arteriosclerosis of senility. The rationale of this treatment is based upon the now generally accepted hypothesis thatnicotinic acid may produce its beneficial effect in many confusional states by means of cerebrovasodilation. Nicotinic acid is most beneficial in confusional states and psychosis of recent onset, and that it must be administered promptly because reversible changes in cellular function are followed quite rapidly by irreversible structural changes. Thus, on the basis of this study, nicotinic acid may be of more benefit in prophylaxis than in cure.
Before the introduction of the oral treatment of Metrazol and nicotinic acid such patients had only symptomatic treatment. Because of the high cost and temporary effects of these drugs.
I was interested in trying some Indian Herbal Drugs which may help the poor population of our country. The herbal drug selected for these studies was SILEDIN (Alarsin).
The ingredients of SILEDIN and their therapeutic actions are discussed by Dr. Hakim in a paper read at Sixth Gujarat & Saurashtra Provincial Medical Conference at Baroda and by Dr. S. R. Soni in a paper read at 32nd All India Medical Conference at Jaipur. The drug is under research as far as its pharmacological work is concerned.
DOSE: Because of the immediate actions of vasodilation of nicotinic acid I used Pelonin (Glaxo) 2T.D.S. with SILEDIN 2T.D.S. Pelonin was given for one month, and then it was discontinued. Then only SILEDIN was given for a period of three months. After three months the dose was reduced to 1 T.D.S. for future period of six months, to one year. The patient belonged to 55 to 88 years age group. One patient with 210 B.P. and hemiplegia, showed improvement, but died after one month's treatment due to fresh attack of apoplexy. Two patients who had severe secondary cardiac failure did not show much improvement with about11/2(One and half) months treatment and the treatment was discontinued. Two patients showed very good improvement but discontinued the treatment-one after one month's treatment and the other after 2 1/2month's treatment and the follow up was not done.
Out of the remaining 7 cases two did not show improvement. The period of abnormal symptoms observed by the relatives was 1 ½ years and 3 years respectively. In 5 patients the duration of the symptoms observed was from 2 to 14 months. The results achieved were excellent, regarding the mental symptoms and physical health. As far as the explanation for the actions of SILEDIN is concerned, till the observations of the pharmacological research which is under progress are published, at this stage I can only repeat what Moore and his co-workers who have worked on histamine and nicotinic acid therapy in this particular disease have to say for the actions of these two drugs. They have stated, "We believe intravenous his- tamine-nicotinic acid dilation therapy actually improves the function of physiologically impaired or non-functioning brain cells. Whether this is a result of increased cardiac out-put, increased vasodilation of cerebral vessels, increased capillary permeability, or an actual physiological action on the cells we do not know."
1. Noyes: Modern Clinical
2. Henderson &Gilepsy: Text Book of Psychiatry.
3. Levy : Pharmacological treatment of the aged patients. J.A.M.A. 153(4) 1260-65, 1953.
4. Chesrow& Others: Metrazol in arteriosclero associated with Senility , Geriatrics, 6'319-23,
5. Maurice E Linden & others: Interdisciplinary research in use of oral Metrazol, Paper read at
Conferences of Americal Psychiatric Association, 1954.
6. Hakim R. A.: Indigenous drug in the treatment of Mental Diseases.