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277. Case of Dementia Described.-"Passing to the male wards," says Dr. Crichton Browne in his able clinical lecture on senile dementia," you encountered Joseph Baged seventy-four, pawnbroker, from Leeds, who, on being interrogated, gave the following account of himself: 'I am twenty-two years old, and came here this morning, having walked over from Doncaster. I am a schoolmaster by trade, and have been at all the best colleges in London. This is Monday, and to-morrow will be Friday. I am so poorly that my lips cling together. I have no money, but can get some from my friend, Mr. L—.' After pausing a few moments, I again put the same series of questions to Joseph Band elicited the following somewhat inconsistent version: 'I am forty years old, and a married man. My wife and I came here last Sunday from New Wortley. I am in the glove and hosiery trade, and was trained in Leeds. This is Tuesday, and to-morrow will be Wednesday. I never was in better health in all my life. I should have £30 in my pocket, but I can't find it.' Further questions followed, and the result of the examination must have been to satisfy you that Joseph B's memory is completely gone, and that his mind is generally much enfeebled. Watching the old man's manner, you might have thought that he was explaining himself with great accuracy. He was neither excited nor depressed. He replied to questions readily and courteously, but his whole discourse was inaccurate and incoherent. His features, much wrinkled, still wore an expression of intelligence. In his eyes the arcus senilis was distinctly seen, while on his temples the temporal arteries were observed to stand out prominently and to pursue a very tortuous course. Touched by the fingers, these arteries were felt to be hard and unyielding, as were also the radical arteries of the wrist. The hands of Joseph B― trembled much, and his gait, when he walked, was tottering, and his whole aspect was that of an infirm, brokendown old man. Referring to the case-book, we found that Joseph B having suffered reverses in business, showed signs of mental decay two years ago. His memory gradually failed, he became childish and physically weak, and was ulti

The British Medical Journal, May 9, 1874.

BR. INS.-26

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mately sent to the asylum because he was restless at nights, and was constantly wandering away from home and losing himself. It is reported of him that he is always cheerful and tranquil, but that he is confused in his ideas, and can never tell where he is, nor recall recent experiences. He is constantly mistaking the identity of persons around him, and making ridiculous blunders. He is occasionally sleepless and restless. His appetite is good."

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2278. Dementia Distinguished from Idiocy.-There is not much practical difficulty in distinguishing between this disease and that of imbecility or idiocy.' As we have seen, idiocy, and probably imbecility, is congenital, and, to return to our metaphor, these might be compared to a barren land which could not be cultivated, or which, at best, with much labor would yield but a scanty, stunted crop. Idiocy is not a mental loss, because a man cannot be said to lose what he never had: it is a sort of natural destitution of mind. mentia is the loss of powers which were in possession, and were capable of development. But still the result is very much the same. The later stages of dementia very closely resemble the more marked degrees of idiocy. In the other stages, there is little diffculty in distinguishing between these two forms of mental defect. It is not difficult to distinguish а house which the builders have left before it was completed from one which has been partially pulled down; so it is with these two diseases. In the one it is the poverty of a fortune which was never achieved, in the other it is the poverty of a fortune which has been broken down. Dementia never appears until the age of puberty, and it is progressive in its gradual obliteration of mind, which ends in blank fatuity. The thorough coherence of thought is a condition of strong health. A great man is a man who reasons correctly about great subjects, but a languid incoherence is the characteristic mental condition of persons laboring under dementia. It is such incoherence as is caused by a lack of energy to think: the incoherence of mania is due to the inordinate excitement and energy which is the spring of action.

[203

See M. Ferrus' Leçons Cliniques faites à Bicêtre.

"The defect in naturals," [idiots,] says Locke, "seems to proceed from want of quickness, activity, and motion in the intellectual faculties."

279. Dementia Distinguished from Mania. There is a disorder of idleness, and a disorder traceable to business. It is not one faculty that is decayed-every faculty is enfeebled. It is a state of general effeteness. Memory suffers, the past is forgotten, and what is remembered by the dement resembles what a sane man remembers of his dreams. Those parts of the past which live in him are those which are most remote from the present. The circumstances which occurred previous to the inception of the disease are remembered long after recent events have passed out of the keeping of memory. Attention, which we have somewhere called the focusing of that camera, mind, is impossible to the dement. Dementia is the inertia of rest, mania the inertia of motion. "No flood of ideas overwhelms him [the dement,] says Dr. Crichton Browne: "on the contrary, a mere driblet of thought trickles through him." When the power of concentrating consciousness is lost, all possibility of mental improvement is gone, and where there is no possibility of improvement there is almost a certainty of deterioration. As a reason for all this, there are pathological changes going on in the brain, and a post-mortem examination will frequently disclose lesion of structure, and diminutions of size, which will have a closer relation to the stage of the disease at which death took place. Nothing is more curious than the gradual enfeeblement and impairment of many of the bodily functions in consequence of the disease which exists in the brain or nervous centres. It is certain that it is the mind that keeps the body alive as well as makes the body rich. This may truly be, because it is use that keeps the functions in 204 repair, as it is use keeps a lock from rusting; but as it is the mind that dictates the use, our assertion is none the less true.

280.

Dementia as Distinguished from the Infirmity of Age. One circumstance must be remembered, and that

Essay on the Understanding, b. ii., c 12, § 13.

is, that dementia is not simply an enfeeblement exactly similar to the mental infirmity of extreme old age. Even in old age there are pathological changes going on which account for the mental symptoms of old age's drivelling, but that these pathological changes are not the same as those which exist in cases of dementia is certain. Death is a natural thing at a certain age. A man is wound up to go for a certain time, as a watch is: to grow and blossom at a certain season, and wither at another like a plant; but if some untoward circumstance limits his threescore and ten years, as if the watch stopped before its time, we might fairly regard the limitation or the stoppage as unnatural, using that word in its narrowest conventional sense. Now, so it is with old age as compared with dementia. Old age is life coming to its natural end: the watch is run out. But dementia is something more: it is the occurrence of circumstances inimical to life other than those which may be classed under the phrase premature old age. There is an actual derangement of mind. In old age, the senses are the first part of a man to fail: the infirmity creeps inward. In dementia, it is the inner sense which first manifests decrepitude: the infirmity spreads outwards. In dementia, memory fails before sight is affected. The man forgets everything that happened yesterday or last week: he forgets people's names; and it is scarcely in the same way that an old man's memory is defective. The old man is puzzled: he knows he has forgotten the name. He institutes a search in memory, and cannot succeed in recovering tho name, but the dement may probably be altogether lethargic, or give a name to the individual which really belonged to some acquaintance of times long since passed.

281. The Incoherence of Dementia considered Psychologically.-The derangement of the mind of the dement is strikingly displayed if we examine any of his thoughts in relation to the laws of association. We are strongly impressed with the belief that in health we find, as it were, the type of every mental disease. Error is only a part of a truth taken for the whole, as Cousin observes, but even in truth we find this same tendency under the name of a figure of speech, which is called synecdoche. So it is in the above question,

the disease is really found in the health just as the error is in the truth. We find some healthy propensity exaggerated, and that is a disease. Now in examining the 205 relation of dementia to one of the most curious of mental laws, we will find an example of this principle. Sir William Hamilton, while speaking of the laws of association, tells how once when he thought of Ben Lomond he immediately afterwards thought of the organization of the Prussian army, and it was only after some time that he was able to trace the connection between these two ideas. He remembered, however, that upon one occasion when he had clambered up out of the world, as it were, upon that Babel of a hill, that he met at the top a Prussian officer. This, he says, was the link between those two somewhat widely separated thoughts. This, then, seems to be a condition of the healthy action of mind. that two thoughts may appear in association without, at the same time, forcing upon the attention the associating thought: as a man may remember he has a wife without reasoning directly from the fact of his marriage. Now, in dementia what seems to be spontaneity in ideas is to be accounted for by the absolute forgetfulness of the intermediate associations. Sir William, by taking thought, was able to recall the memory of the Prussian officer and his relation to the idea of Ben Lomond. The individual who suffers from dementia is unable to recall the intermediate thoughts by any effort of will: indeed, he is unable to make the effort which would be necessary. Such an explanation as this explains philosophically the incoherence which exists in dementia, for spontaneity of thought is a kind of incoherence. Is it not in this fact that the truth of the observation of the close connection which exists between eccentricity and genius lies?

282. Mental Symptoms of Dementia.-But it is the coherence of thought that is the coherence of nature. To the dement the world soon becomes unintelligible. Familiar objects are not recognized; places in which he has resided are mistaken for other places; times are forgotten; the future is not, the present is a haze, the past is dim. He cannot

Lectures on Metaphysics.

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