away traveling; but in a couple of years he took advantage of my going away and began to go by himself and climb hills in the White Mountain district. While the irregularity of the heart continues unchanged he is to-day in better condition than the average man of the age of eighty. For kidney symptoms the albumin and casts have repeatedly suggested an unfavorable prognosis until, in time, the fact was recognized that the interstitial nephritis connected with general arteriosclerosis does not advance to any extent in many cases when the patient is placed under good conditions. As for cerebral arteriosclerotic symptoms, I feel that giddiness and vertigo stand out prominently as particularly puzzling symptoms. They are the baffling symptoms. I recall in illustration, a patient then aged about seventy-five who, six years ago became so possessed with vertigo (a sea-sick feeling) when she suddenly changed her position, especially when taking articles down from a high shelf, or when she began a meal that she had to lie down; in short, whenever there was a quick disturbance of the circulation of the brain, the symptoms of vertigo were so marked that she caused me a great deal of thought and care until I had studied and understood her. These symptoms disappeared in a few years, but have been intermittent since. She is, however, now a very active housekeeper, commencing her duties early each morning. It is unnecessary to multiply cases illustrating the importance of waiting months or years if necessary, until symptoms-often alarming of heart, kidney or brain have been carefully watched long enough to determine whether they belong to general arteriosclerosis or are only of local origin. We all learn by experience how baffling are the cerebral arteriosclerotic symptoms showing themselves by the varieties of vertigo, and how much patients improve under good conditions. Even arteriosclerotic epileptiform attacks have less effect upon the patient's mental condition than would be expected. How much we wish to know the condition of the cerebral circulation in these cases. This optimism and fortunate prognosis depends upon placing the elderly patient under good conditions, upon relief from worry and care, upon producing ease of mind by travel, agreeable occupation, and by fads. I will end as I began by a quotation from an elderly patient to show that we must use tact and not insist upon ideal treatment against our patient's wish. In trying to influence a patient, this week, to go to the hospital for a few days, to be under observation-telling him that this was the safe course to take, he said, "Doctor, I will go if I get decidedly worse, but I feel that a man who is nearly 78 years of age has earned a right to take some risks and decide for himself." In this short paper I must apologize to the members of this society for having told them nothing new. I hope, however, that a brief resumé of one's convictions of the importance of a practical use of the modern method of classifying arteriosclerosis and of studying the arteries, and of optimism with regard to the benefit of the extensive study now being made of the subject may be worth expressing here. THE HISTORY AND USE OF THE TERM DEMENTIA.' By G. ALDER BLUMER, M. D., Medical Superintendent, Butler Hospital, Providence, R. I. The history of the term "dementia" epitomizes that of psychiatry itself. Beginning with its ancient Roman use when in the speculative philosophy of Cicero' amentia was its accepted synonym, and when the conception was that of the English "madness," and coming down the centuries to modern times, it is a term that has been applied to a host of varying conditions. Indeed, within the past three years the attempts at precise interpretation of even our youngest, most aspiring, and least fallible, alienists have been hopelessly baffled by the wide, loose, and vague use of this locution. For who is there here that cannot recall instances very many within that brief period when "acute dementia" has been used to connote on the one hand conditions of mental bewilderment and confusion and on the other to characterize terminal and incurable states-states, albeit, differing as the poles asunder in etiology and underlying pathogenesis? In the strenuous endeavor of modern psychiatry sharply to differentiate morbid mental states and therein, perchance, to find the key to prognosis and treatment, this indiscriminate use of the word dementia has been responsible for deplorable confusion alike in the literature and the minds of its students. One might suppose, from the numerous compound words in which it appears, that no matter how indefinite the qualifying term of that compound, the substantive itself had a precise significance of common agreement. Thus, from the descriptive terms involutional, senile, presenile, paretic, precocious (with the three varieties, paranoid, hebephrenic, and catatonic dementia), alcoholic, toxic, syphilitic, 'Read at the sixty-second annual meeting of the American MedicoPsychological Association, Boston, June 12-15, 1906. 2 Animi affectionem lumine mentis carentem nominaverunt amentiam eandemque dementiam. Tusc. 3, 5, 10. traumatic, organic, post-apoplectic, paralytic, hysteric, acute, chronic, primary, secondary, terminal, and even congenital dementia, one might infer that each of these states exhibited certain well-recognized features common to all, the difference being merely as to age, genesis, etiology, etc. If, however, it should be judged from this free, though apparently positive, use of the word that its psychological definition and analysis could be readily ascertained, grievous disappointment and perplexity would follow an attempt to gain a knowledge of the prominent features of the analysis as expounded by different authors. Take, for instance, the latest edition of so well-known a text-book as Church and Peterson and we find our authors speaking of dementia as a term employed to designate simple mental enfeeblement of all the mental faculties, and again declaring that in medicine it signifies only a general weakening of a mind once normal. Though a sharp distinction is here drawn between a congenital mental weakness and dementia, with this definition as a criterion, the term could be applied to any acute mental disturbance. The more modern conception of dementia as a permanent and incurable defect receives no mention in this work. "Dementia," observes Esquirol, "must not be confounded with imbecility or idiocy. In imbecility neither the understanding nor the sensibility has been sufficiently developed. He who is in a state of dementia has lost these faculties to a very considerable degree. The former can neither look backward nor into the future; the latter has recollections and reminiscences. Imbeciles are remarkable for their conversation and acts which greatly resemble infancy. The conversation and manners of the insensate bear the impress of their former state. There exists, therefore, a form of mental alienation which is very distinct-in which the disorder of the ideas, affections, and determinations is characterized by feebleness and by the abolition, more or less marked, of all the sensitive intellectual and voluntary faculties: this is dementia."" Griesinger says, "In all these cases of dementia the funda Quoted by Bucknill and Tuke, Psychological Medicine. First English edition published in 1858. 'Griesinger. Mental Pathology and Therapeutics, 1861. mental disorder consists in a general weakness of the mental faculties. In the sphere of the emotions this is manifested in the increasing incapacity of the patients for any profound emotion with irregular change of quite superficial emotions or persistent complete indifference. . . . It is this indifference which shows. the abnormal state of the emotional reactions toward the external world (laughing and amusing themselves in the midst of the saddest events, etc.). . . . With the complete indifference and absence of all actual desires which characterize the patients we sometimes see manifested disorderly mental movements and aimless, extravagant impulses whose meaning the patient himself cannot understand, and the reaction of the will where this still exists has throughout the character of transitoriness and inconstancy." Clouston defines "mental enfeeblement," using the term in a special and scientific sense [dementia?], as "A general weakening of the mental power comprising usually a lack of reasoning capacity, a diminution of feeling, a lessened volitional and inhibitory power, a failure of memory, and a want of attention, interest, and curiosity, in a person who had those mental qualities and lost them, or has come to an age to have them and they have not developed." Henry Maudsley takes dementia to be "the destruction or loss. of mind, as distinguished from amentia, which is used to denote idiocy or the privation of mind occasioned by causes that have acted before or soon after birth-that is to say, before there has been a change of its development." For E. C. Spitzka" "primary mental deterioration is an uncomplicated enfeeblement of the mind occurring independently of the developmental and involutional periods." Charles Mercier says, "Clinically, the term 'dementia' is used to characterize the very large group of cases in which diminution of intelligence constitutes the most conspicuous feature of the malady." Clouston, Clinical Lectures on Mental Diseases, 1883. 'Henry Maudsley, The Pathology of Mind, 1879. 'E. C. Spitzka, Manual of Insanity, 1887. |