Dementia during the nineteenth century
- Jun 20, 2011
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).
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