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MISCELLANEOUS GROUPS (Concluded).
SENILE dementia may be defined as a peculiar state of intellectual enfeeblement, with or without delusions, resulting from cerebral lesions determined by senility.
Age is here, therefore, the great etiological factor; it is, however, not the sole factor. Many individuals attain extreme old age without presenting any appreciable intellectual disorders; others, on the contrary, have scarcely passed over the threshold of senility when they are already veritable dements.1 The effects of age are the more powerful and the more precocious the more marked the predisposition. Heredity, the intoxications (alcoholism), overwork, violent and painful emotions, traumatisms, etc., are also frequently given as causes.
Statistics furnish a rather small proportion of congenitally predisposed persons among senile dements, but this is perhaps partly due to the fact that it is frequently impossible to obtain reliable family histories in such cases.
Senile dementia is rare before the age of sixty
1 Russell. Senility and Senile Dementia. Amer. Journ. of Insanity, 1902.
years. Alcoholism sometimes brings about an analogous state of intellectual enfeeblement, appearing towards fifty or fifty-five years, which has been designated by the term sænium præcox.1 Such cases are exceptional if we exclude ordinary alcoholic dementia. The onset sometimes follows some strong emotional shock, financial troubles, or a somatic affection. Almost always it is insidious, marked simply by a change of disposition and slight disorders of memory. When fully established the dementia presents the following fundamental elements:
(a) Impairment of attention and sluggishness of association of ideas, readily demonstrable by psychometry, as has been shown by the experiments of Rauschburg and Balint.2 (These authors performed their experiments upon cases of simple senile dementia without delusions.) A curious fact observed in these experiments is that associations of ideas were
1 Cases essentially of premature senility have been described under the name of Alzheimer's disease. See Alzheimer. Ueber eigenartige krankheitsfälle des späteren Alters. Zeitschr. f. d. gesamte Neurol. u. Psychiatrie, Vol. IV, p. 365. Perusini. Ueber klinisch und histologisch eigenartige psychische Erkrankungen des späteren Lebensalters. Nissl's Arbeiten, Vol. II, p. 297.- S. C. Fuller. A Study of the Miliary Plaques Found in Brains of the Aged. Amer. Journ. of Ins., Oct., 1911.- S. C. Fuller. Alzheimer's Disease (Senium Præcox): The Report of a Case and Review of all Published Cases. Journ. of Nerv. and Ment. Dis., Vol. XXXIX, 1912. S. C. Fuller and H. I. Klopp. Further Observations on Alzheimer's Disease. Amer. Journ. of Ins., July, 1912. — W. J. Tiffany. The Occurrence of Miliary Plaques in Senile Brains. Amer. Journ. of Ins., Jan., 1914.
2 Ueber qualitative und quantitative, etc. Allgem. Zeitsch. für Psychiat., 1900.
almost always determined by the sense of the words, and rarely by similarities of sound or by rhymes. It will be remembered that associations by similarities of sound are the result of automatic psychic activity; it seems, therefore, that mental automatism, instead of being exalted, as it is in certain psychoses (mania), is like voluntary psychic activity, diminished, at least in simple senile dementia without delusions.
(b) Inaccurate and incomplete perception of the external world, the consequence of which is the production of numerous illusions and of disorientation of place.
(c) Disorders of memory, comprising:
(I) Amnesia of fixation (anterograde amnesia), which entails disorientation of time;
(II) Amnesia of conservation (retrograde amnesia), which is progressive and which follows almost perfectly the law of retrogression;
(III) Illusions and hallucinations of memory, which form the basis of pseudo-reminiscences, often absurd or puerile in character and varying from one instant to another.
(d) Impoverishment of the stock of ideas: old impressions disappear and are not replaced by new This is the cause of the tiresome repetitions
in the discourses of old dotards.
(e) Loss of judgment: the patient does not accept new points of view. He mourns for the good old times and shows a profound contempt for new ideas which he is incapable of assimilating. This contempt for the present is met with in many old people,
but not in combination with any appreciable mental deterioration.
The senile dement has no realization of his own condition. Often he boasts of his endurance, his strong will, his lucid mind, and declares that he is in no need of assistance from any one and that he is quite well able to manage his own affairs.
(f) Diminution of affectivity, morbid irritability: hence the indifference of senile dements for their relatives and their interests, their unprovoked outbursts of anger, their tyrannical tendencies, and their occasional emotionalism.
(g) Automatic character of the reactions: from this point of view senile dements may be divided into two classes: the turbulent and the apathetic.
The turbulent are always moving, intrude everywhere, give unreasonable or contradictory orders, get up during the night and wander about the house with a candle in their hand at the risk of starting a fire. Their mood is either depressed or elated and hypomaniacal. Sexual excitement, most often purely psychic, is quite likely to be associated with this state, and, together with the intellectual enfeeblement, leads the patient to dangerous acts: attempts at rape, indecent exposures, etc.1
The apathetic senile dements have an indifferent, stupid aspect. The patient's mouth, half open, allows the saliva to dribble; he remains motionless upon the chair where he has been placed; he is docile,
1 By the term exhibitionism has been designated a morbid tendency, which certain psychopaths have, to exhibit publicly their genital organs.
obedient, and very suggestible. When in the hands of unscrupulous persons, he allows himself without protestation to be swindled and maltreated, and unconsciously yields to inveiglements for imprudent disposal of his property.
In advanced stages of the disease the turbulent as well as the apathetic senile dements frequently become filthy, often soiling and wetting themselves.
Sleep is diminished and often even absent in the excited forms. On the other hand, constant somnolence is frequent in the apathetic cases.
Together with the dementia there are the regular signs of senility. The skin is wrinkled and discolored; the hairy system is undergoing atrophy; the patellar reflexes are sometimes abolished, but more frequently exaggerated; the pupils are slightly myotic and paretic; arcus senilis is well marked; there is hypoæsthesia of all the senses; all movements are awkward and uncertain; there is diminution of the muscular power; senile tremors affect the entire body and especially the head, consisting of coarse oscillations.
The cardio-vascular symptoms are of great importance.
The frequent association of senile dementia with arteriosclerosis has already been mentioned. Vascular disease is, however, not invariably present and is often but slight: senile atrophy is a process essentially independent of arteriosclerosis.
The appetite is diminished, or, on the contrary, it may be exaggerated to a degree constituting voracity. In the latter case the patient's diet should be care