One attack is the rule, although several, probably of an epileptic nature, have been reported. It is an extremely difficult condition to diagnosticate with certainty, and is therefore often the refuge of criminals and a resource of criminal lawyers. The most likely honest mistake liable to be made regarding it is to confound it with an outburst of passion.
PRIMARY DEMENTIA (Acute dementia, Stuporous insanity, Anergic stupor) is a disease chiefly of youth and early maturity in persons of inherited weakness or under the influence of prolonged exhausting conditions, to which some mental shock usually adds the immediate cause. Although most of the cases are under the age of twenty-five, it occurs up to forty-five. Masturbation is so common a symptom in its course—and it may be one of the debilitating and enervating factors constituting a predisposing cause—that most of the primary dementia is classed in some asylums as insanity of masturbation. There may be an initial stage of a number of days, marked by moderate melancholia or by maniacal excitement, but there is usually mental torpor advancing rapidly to pronounced dementia. In rare cases there is marked chorea, and slight choreic movements are often observed. The course of primary dementia may be subacute and advance with extreme slowness.
There is no overwhelming delusion paralyzing the mind, so to speak, as in melancholia attonita (melancholia with stupor). In acute cases the brain quickly falls into a state of profound anæmia, precisely such as is found post-mortem in starved dogs, and loses its power to a greater or less extent of reacting to the stimulus of the senses. There is little or no sensation of hunger, the sensory nerves are nearly or quite paralyzed, the bladder and rectum become distended until urine and feces are voided unconsciously or at least uncontrolled, and voluntary movements almost cease, although the muscles are capable of acting if directed: if led or pushed, the patient walks; if placed in a chair or bed, remains there; and in the worst cases lies on the floor quite inattentive to all the decencies of life unless constantly looked after. There is always partial, and there may be complete, anæsthesia, to such an extent that even the involuntary muscles do not respond to the ordinary stimuli. There is rapid loss of flesh, very sluggish circulation, and feeble heart-action. After recovery the patient speaks of the stage of his greatest illness as a blank in his memory.
This description of pronounced cases of primary dementia of the most severe type needs modification as applied to milder cases, which may exist in all degrees, down to a state of mental impairment of very moderate extent.
The mental impairment may be progressive and quite incurable, but also so slight in the beginning, and may make such slow progress, as to entirely escape detection for several years, and then attract attention at first by the lowered plane of character and loss of self-control in little matters of daily life, rather than by the intellectual deterioration, which by that time has become quite marked. This subacute form of primary dementia in young people rarely finds its way into the insane asylum until the second, third, or fourth year of its course, and then its progress is slowly downward. It has none of the eccentric or grotesque features of hebephrenia, and little of its emotional disturbances.
Subacute primary dementia in the later years of maturity, just before or several years before the climacteric, is of grave import, as it indicates the development of an hereditary predisposition to insanity in a form which not only offers no reasonable hope of recovery, but also is quite certain to manifest a change of character which is even more difficult to treat and properly control than the intellectual failure. As it is most likely to arise under circumstances of wear and worry, its symptoms may be for a long time attributed to disappointment or bad temper. After the dementia becomes pronounced its downward course is seldom otherwise than very rapid.
SECONDARY DEMENTIA is a convenient name for the curable dementia which appears at the subsidence of acute symptoms occasionally in mania, and rarely in melancholia—that is, just about the beginning of the period of convalescence. It is also called secondary stupor.
In primary and secondary dementia, resulting in recovery, the progress of the disease is rarely otherwise than very rapid, and unless a cure takes place in a few months at the outside, secondary changes occur in the brain and the tendency is to terminal or incurable dementia. So many cases are treated outside of asylums that it is difficult to estimate the cure-rate, but it is probably not less than 60 or 70 per cent., although it is quite common in the apparent cures for the brain to remain on a lower intellectual or moral plane than if the disease had not occurred.
TREATMENT does not involve the necessity of removal from home in the acute cases, except when that is demanded for convenience of treatment. There is no melancholia to suggest the possibility of suicide, and no mental exhilaration or motor excitement to make restraint necessary. The most important indications are met by abundant, easily-assimilated food, which must usually, for a time at least, be given with a spoon or by the stomach-tube; fresh air, attention to the processes of digestion, relief of the gastro-intestinal catarrh by the usual remedies, stimulating baths, tonics, stimulants, and general galvanism. Proper care in emptying the bladder and rectum and entire cleanliness will suggest themselves.
In mild cases a tonic and stimulating regimen, including sea-bathing and gymnastics, will often be sufficient.