Dementia during the nineteenth century
There is a major difference between eighteenth-century views on dementia and what the historian finds a century later when dementia starts to refer more or less specifically to states of cognitive impairment mostly affecting the elderly, and almost always irreversible. The word ‘amentia’ was no longer used in this context and started to name a ‘psychosis, with sudden onset following severe, often acute physical illness or trauma’ (Meynert, 1890). The syndromatic view of the dementias was still in use but mainly in regards to the ‘vesanic dementias’, i.e. terminal states for all manner of mental disorders. This section will explore such momentous changes.
In his doctoral thesis, Esquirol (1805) used the word dementia to refer to loss of reason, as in démence accidental, démence mélancolique; then, he distinguished between acute, chronic and senile dementia. Acute dementia was short-lived, reversible, and followed fever, haemorrhage and metastasis; chronic dementia was irreversible and caused by masturbation, melancholia, mania, hypochondria, epilepsy, paralysis and apoplexy; lastly, senile dementia resulted from ageing, and consisted in a loss of the faculties of the understanding (Esquirol, 1814). Esquirol’s final thoughts on dementia were influenced by his controversy with Bayle (1822) who via his concept of chronic arachnoiditis propounded an anatomical (‘organic’) view of all the insanities and scorned Pinel’s views that some vesanias might develop in a psychological space (Bayle, 1826).
Together with his student Georget, Esquirol supported a ‘descriptivist’ approach, at least in relation to some forms of mental disorder. He reported 15 cases of dementia (seven males and eight females) with a mean age of 34 years (SD = 10.9), seven being, in fact, cases of general paralysis of the insane, showing grandiosity, disinhibition, motor symptoms, dysarthria and terminal cognitive failure.
There also was included a 20-year-old girl who, in modern terms, suffered from a catatonic syndrome; and a 40-year-old woman with pica, cognitive impairment, and space-occupying lesions in her left hemisphere and cerebellum (Esquirol, 1838). Although the mean age of these samples and the absence of cases of senile dementia may simply reflect a short life expectancy in Esquirol’s day, or that at the Charenton Hospital some selection bias was in operation, it is more likely to reflect the view that age was not an important variable. Together with irreversibility, age became a defining criterion only by the second half of the nineteenth century.
Like his teacher Esquirol, aware of the importance of clinical description, Calmeil wrote: ‘It is not easy to describe dementia, its varieties, and nuances; because its complications are numerous … it is difficult to choose its distinctive symptoms’ (p. 71). Dementia followed chronic insanity and brain disease, and was partial or general. Calmeil was less convinced than his co-student Georget that all dementias were associated with alterations in the brain.
In regards to senile dementia, Calmeil remarked: ‘there is a constant involvement of the senses, elderly people can be deaf, and show disorders of taste, smell and touch; external stimuli are therefore less clear to them, they have little memory of recent events, live in the past, and repeat the same tale; their affect gradually wanes away …’ (p. 77). Although a keen neuropathologist, Calmeil concluded that there was no sufficient information on the nature and range of anomalies found in the skull or brain to decide on the cause of dementia (pp. 82-83) (Calmeil, 1835).
A Ghent alienist, thinking in Flemish and writing in French, Guislain believed that in dementia:
All intellectual functions show a reduction in energy, external
stimuli cause only minor impression on the intellect, imagination
is weak and uncreative, memory absent, and reasoning patho-
logical. There are two varieties of dementia … one affecting
the elderly (senile dementia of Cullen) the other younger
people. Although confused with dementia, idiocy must be con-
sidered as a separate group (p. 10). [In dementia,] ‘the patient
has no memory, or at least is unable to retain anything … impres-
sions evaporate from his mind. He may remember names of
people but cannot say whether he has seen them before. He does
not know what time or day of the week it is, cannot tell morning
from evening, or say what 2 and 2 add to … he has lost the instinct of preservation, cannot avoid fire or water, and is unable
to recognize dangers; has also lost spontaneity, is incontinent
of urine and faeces, and does not ask for anything, he cannot
even recognize his wife or children … (p. 311) (Guislain, 1852).
Because in the past the mentally ill: ‘had been categorized only in terms of a [putative] impairment of their mental faculties …’ (p. 2), Morel (1860) endeavoured to develop a taxonomy that distinguished between occasional and determinant causes of mental disorder (p. 251) and suggested six clinical groups: hereditary, toxic, associated with the neuroses, idiopathic, sympathetic and dementia In regards to the latter, Morel (1860) believed that:
… if we examine dementia (amentia, progressive weakening of
the faculties) we must accept that it constitutes a terminal state.
There will, of course, be exceptional insane individuals who,
until the end, preserve their intellectual faculties; the major-
ity, however, are subject to the law of decline. This results from
a loss of vitality in the brain … Comparison of brain weights in
the various forms of insanity shows that the heavier weights
are found in cases of recent onset. Chronic cases show more
often a general impairment of intelligence (dementia). Loss in
brain weight – a constant feature of dementia – is also pre-
sent in ageing, and is an expression of decadence in the human
species. [There are] natural dementia and that dementia result-
ing from a pathological state of the brain … some forms of
insanity are more prone to end up in dementia (idiopathic)
than others … it could be argued that because dementia is a ter-
minal state it should not be classified as a sixth form of men-
tal illness … I must confess I sympathize with this view, and it is
one of the reasons why I have not described the dementias in any
detail … on the other hand from the legal and pathological view-
points, dementia warrants separate treatment … (pp. 837-838).
Morel’s view is in keeping with his ‘degenerationist’ hypothesis, which he himself had developed three years earlier (Morel, 1857; Pick, 1989). One consequence of this view was that there were no specific brain alterations in dementia.
In spite of his early death, L. F. Marce published a series of important articles on the neuropathology of senile dementia which challenged Morel’s non-specificity hypothesis.
There is no space in this section to analyse with the same level of detail the evolution of the concept of dementia in other European countries, although it can be said that it followed similar lines. Views in England, for example, were mainly derivative from French ones. In a popular textbook, and following Pinel, Esquirol and Calmeil, Prichard included a category which he called ‘incoherence or dementia’:
[it] is a very peculiar and well-marked form of mental disorder.
The mind in this state is occupied, without ceasing, by uncon-
nected thoughts and evanescent emotions; it is incapable of
continued attention and reflection, and at length loses the fac-
ulty of distinct perception or apprehension. Numerous examples
of this disease, or decay of the mental powers are to be met
within every receptacle containing a considerable assemblage
of deranged persons … incoherence is either a primary disease,
arising immediately from the agency of exciting causes on a
constitution previously health, or it is a secondary affection,
the result of other disorders of the brain and nervous system
which, by their long duration or severity, give rise to disease
in the structure of those organs … secondary incoherence or
dementia follows long-protracted mania, attacks of apoplexy,
epilepsy or paralysis, or fevers attended with severe delirium.
This decay of the faculties has been termed fatuity or imbecil-
ity, and it has been confounded with idiotism, which in all its
degrees and modifications is a very different state … (pp. 83-85)
The same can be said of the views expressed by Bucknill and Tuke in their popular textbook:
Dementia may be either primary or consecutive; acute or
chronic. It may also be simple or complicated; it is occasion-
ally remittent but rarely intermittent. It is primary when it is
the first stage of the mental disease of the patient; and when
this occurs, it is, perhaps, one of the most painful forms of insan-
ity; the patient often being acutely sensible of a gradual loss
of memory, power of attention, and executive ability. At this
period, the distinction is often well marked between the strictly
intellectual and affective disorder … dementia is much more
frequently consecutive, that is the consequence of other dis-
eases of the mind. Thus during 44 years, while 277 cases of
mania and 215 of melancholia were admitted at the Retreat,
only 48 of dementia were admitted during the same period;
yet, at the end of that term, there were remaining in the insti-
tution, 20 patients in a state of dementia out of 91 inmates.
Mania very often degenerates into dementia; as also do melan-
cholia and monomania … it should be observed, that the term
dementia may be, and sometimes is, too indiscriminately
employed. All writers of authority agree in representing impair-
ment of the memory as one of the earliest symptoms of demen-
tia; but we believe cases are occasionally classed under incipient
dementia, in which close observation would show that the
memory is unimpaired … It is often rather a torpid condition of
the mind, falling under the division ‘apathetic insanity, which
ought not to be confounded with dementia …’ (pp. 117-119)
(Bucknill and Tuke, 1858).
The same concepts are found in German-speaking nations and the views of Heinroth, Feuchtersleben, Griesinger and Kahlbaum were influential until the beginning of the second half of the nineteenth century. Heinroth (1818/1975) used the term dementia in a very broad sense to refer to a state of mind that might accompany or follow other mental disorders, i.e. ‘vesanic dementia’, a term that late in the century was to become very popular, particularly in France. This concept, which is not related to age, is redolent of the later notion of secondary dementia, i.e. the state of psychosocial and cognitive incompetence that might follow a functional psychosis.
Feuchtersleben’s usage (1845/1847) is even more general. In his work he uses dementia as a synonym of madness and may refer to forms of acute madness with and without accompanying idiocy. There is only one form of dementia, which he refers to as moria and considered as more or less chronic and more or less cognitive. Although possibly ending up in a state of idiocy, the patient can also show lucid intervals. Once again, age is of no relevance to moria and hence one must conclude that Feuchtersleben is referring to a form of vesanic dementia.
Griesinger’s nosology is not altogether clear and has often been interpreted as being based on the belief that there is only one form of madness (unitary psychoses concept), which may go through at least three stages: depression (as in melancholia), exaltation (as in mania) and weakness (as in chronic madness and dementia). In the second edition of his great work, Griesinger (1861/1867) insists that the states of mental weakness ‘do not constitute primary but consecutive forms of insanity’ (p. 319). This suggests that he is also referring to a form of vesanic dementia, although he includes under this large class all the forms of mental handicap where no preliminary ‘primary’ forms of madness can be recognized. Under the heading ‘dementia’, Griesinger includes mental disorders fundamentally caused by a ‘general weakness of the mental faculties’ including loss of emotions. Age is not a factor in the development of dementia or apathetic dementia and hence it must also be concluded that Griesinger is referring to vesanic dementia.
The work of Kahlbaum, particularly his important book of 1863 on the definition and classification of mental disorders, mark the beginning of a new era in psychiatry. His incorporation of time as a variable in the analysis of madness (longitudinal definition) and his view that period of life is relevant to the form of the disease remain the pillars of psychiatric nosology to this day. The concept of ‘Dementia’ is dealt with in the third section of Kahlbaum’s book (1863) under the name of aphrenia. This clinical category refers to states of mental impotence (Zustand geistiger Impotenz) (p. 153), which Kahlbaum equates to the old German notion of Blodsinn.
After complaining that neither the Greeks nor Latin writers managed to specify a term for this condition, he insists that a word is needed to refer to states of cognitive and behavioural incompetence such as those seen in dementia terminalis (Berrios, 1996).
Alistair Burns MPhil, MD, FRCP, FRCPsych
Professor of Old Age Psychiatry,
John O’Brien MA, DM, FRCPsych
Professor of Old Age Psychiatry,
Institute for Ageing and Health,
University of Newcastle upon Tyne,
Newcastle upon Tyne, UK
David Ames BA, MD, FRCPsych, FRANZCP
Professor of Psychiatry of Old Age,
University of Melbourne, St George’s Hospital, Melbourne,
German Berrios BA (OXFORD), MD, DM H.C. HEIDELBERG, FRCPsych, FBPSS
University of Cambridge Department of Psychiatry,
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