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Until which period, me, yes, me,
Thus spoke Macaulay, here he choose
That e'er circumfluent ether drew,
And those at present on the stage :
That have been, are, and are to be;
In speaking prose and speaking rhyme :
Macaulay holds the highest station;
Just here Macaulay held his peace,
The above account of Mr. Short and Mr. Pither's interview with the author, must be accepted as the exaggeration of an irritated and unsound mind. Doubtless, these gentlemen conducted and expressed themselves with propriety, forbearance, and self-respect.-ED.
On the Various Forms of Mental Disorder,
(Being the substance of Lectures delivered at the York School of Medicine). By DANIEL H. TUKE, M.D., Visiting Medical Officer to the York Retreat.
(Continued from Page 466, Vol. ii.)
Having disposed of idiocy, cretinism, and imbecility, we will now pass on to the consideration of dementia, monomania, and the delusions, hallucinations and illusions of the insane.
DEMENTIA.-Definition and Description.
Dementia was thus defined by Pinel:-"Rapid succession or uninterrupted alternation of insulated ideas, and evanescent and unconnected emotions; continually repeated acts of extravagance; complete forgetfulness of every previous state; diminished sensibility to external impressions; abolition of the faculty of judgment; perpetual activity."
"Dementia," observes Esquirol, "must not be confounded with imbecility or idiocy. În imbecility neither the understanding nor sensibility have 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 by their conversation and acts, which greatly resemble infancy. The conversation and manners of the insensate bear the impress of their former state. Idiots and cretins have never possessed either memory or judgment; scarcely do they present the features of animal instinct, and their external confirmation indicates clearly enough that they are not organized for thought. There exists, therefore, a form of mental alienation which is very distinct, in which the disorder of the ideas, affections, and determinations is characterised by feebleness, and by the abolition, more or less marked, of all the sensitive, intellectual, and voluntary faculties. This is dementia."
Some of the symptoms of dementia contained in Pinel's definition would appear to belong rather to mania; indeed these two conditions are often intimately connected together, and it very frequently happens that patients in dementia are subject, on the slightest excitement, to maniacal outbursts; and, on the other hand, patients in acute mania VOL. III. NO. 19.
are, in consequence of the rapid flow or succession of ideas, perfectly incoherent; and a stranger to the history of the case might be unable to decide whether the patient were demented and excited, or maniacal and temporarily incoherent. "We have found ourselves," says a modern writer, "often embarrassed in arriving at a diagnosis in such cases; we have, in consequence, been obliged to submit the patient to a more prolonged examination before giving an opinion. It is a good plan to attempt to make them write; if they do, we then see that they [the former] have forgotten their words and letters."
"In many acute diseases," observes Guislain, "there is an oppression, and not an extinction, of mental power. This remark is especially applicable to acute melancholy and acute mania, disorders in which the intelligence appears to be covered with a veil." Pinel thus distinguished dementia from mania:-"In mania there are important lesions of the powers of perception, imagination, and memory; but the faculty of judgment and the association of ideas remain.
In dementia, there is no judgment, either true or false." A considerable proportion of the patients in asylums for the insane afford, unfortunately, examples of dementia in its various stages, from its slightest and most incipient form to that in which the patient has no longer any just perception of the objects around him; can no longer reason; has completely lost the comparing faculty, and has left to him little more than the functions of vegetable and animal life. "Indifferent to everything, nothing affects the demented. They sport and play when others are in affliction. They shed tears and utter complaints when every one else is happy, and when they ought to be so themselves. If their position is unpleasant they do nothing to change it. The brain being in a state of atony, and no longer furnishing sensations for the production of ideas upon which to reason, nor data upon which to form a judgment, the determinations are vague, uncertain, variable, without aim, and passionless. Those who are in a state of dementia are destitute of spontaneity. They no longer determine, but abandon themselves; yielding implicitly to the will of others."*
The outward signs of dementia may, when long continued, be well pronounced in the countenance. It very often happens, however, that when at rest, an observer would fail to discover in the facial expression the mental condition of the patient; but on asking him a question his true state * "Maladies Mentales," (Hunt's Edit.) p. 418.
becomes at once apparent. The vacant and puzzled look,
Fixes instead, unmoulding reason's mintage,
In this, dementia differs from those forms of mental deficiency which have originated in a congenital or infantile condition-idiocy and imbecility-and in which there is an unvarying accordance between the physiognomy and psychical power. In dementia, on the contrary, although occasionally indeed not one stone is left standing upon another of the once glorious temple of thought, we may frequently trace in the yet undistorted facial lineaments many vestiges which bear witness to the patient's original mind.
Esquirol notes among the physical symptoms of dementia,. "a pale face, the eyes dull and moistened with tears, the pupils dilated, the body now emaciated and slender, and now loaded with flesh; the face full, the conjunctivæ injected, and the neck short." This description, however, must be taken in a very general sense, and open to many exceptions. Incurable dementia is but too surely indicated by the inclination of the head forwards. Apart from cases of paralysis there is a general relaxation of the muscular system, often manifested in the walk, and not unfrequently the cause of the crouching attitudes patients in dementia assume. So justly has muscular power been termed the pulse of mental affections.
The physical health of patients thus affected is in general, as Dr. Prichard remarks, tolerably good; they are often fat, have good appetites, digest their food, sleep well, and if in the previous stages of the disease they had been emaciated, they often recover their natural degree of plumpness on the approach of dementia.* Consequently the return of bodily health, unaccompanied by mental improvement, augurs badly for patients suffering from mania or melancholy.
Dementia, or incoherence, may be divided into several stages. The following are those adopted by Dr. Prichard.† The first may be termed that of forgetfulness, or loss of "Treatise on Insanity," p. 96.
memory. Its chief characteristic is a failure of memory, especially as to recent events. The power of reasoning within the sphere of distinct recollection is not remarkably impaired, and the faculty of judgment is exercised in a sound manner.
The second stage brings with it a total abolition of the power of reasoning, depending on a loss of voluntary control over the thoughts. It may be termed a stage of irrationality, or loss of reasoning.
In the third stage the individual affected is incapable of comprehending the meaning of anything that may be said to him. It may be styled the stage of incomprehension. It is the confirmed stage of incoherence; that epithet applying to it in a still more striking manner than to any other degree of the disease. It might also be termed the instinctive stage. Reason being entirely lost, and the instinctive or mechanical principles of action, as they are termed, still remaining in vigour, the latter display themselves more remarkably.
The fourth and last stage is characterised by loss of instinctive voluntary actions. Even the animal instincts are lost. The miserable victim of disease, when reduced to this state, has merely organic or physical existence; he appears scarcely conscious of life, has neither desires nor aversions, and is unable to obey the calls of nature. This is the stage of inappetency, or loss of instinct and volition.
"Scarcely any exhibition of human suffering," observes Dr. Prichard, "can be more deeply affecting than the aspect of a group of lunatics reduced to the last stages of fatuity; and those who have never witnessed such a spectacle can hardly imagine so abject a state of mental degradation. In a group of this description an individual may be seen always standing erect and immoveable, with his head and neck bent almost at right angles to his trunk, his eyes fixed upon the ground, never turning them round or appearing by any movement or gesture to be conscious of external impressions or even of his own existence. Another sits on a rocking chair, which she agitates to and fro, and throws her limbs into the most uncouth position, at the same time chanting or yelling a dissonant song, only capable of expressing a total inanity of ideas and feelings. Many sit constantly still, with their chins resting on their breasts, their eyes and mouths half open, unconscious of hunger or thirst, and almost destitute of the feelings which belong to merely physical life; they would never lie down or rise were they not