CHAPTER XXII.

TERMINAL DEMENTIA.

THE great mass of the inmates of our asylums are cases of terminal stages of mental disease. We have already noticed in connection with the different forms of insanity the general symptoms of the secondary conditions that follow them. While it is often the case that the original condition implants its type to a greater or less extent upon the terminal condition, this is not by any means the universal rule. All forms of insanity of many years' duration, with the exception possibly of certain types of delusional derangement, fall under the general head of terminal dementia. The impaired mental action or dementia is characteristic of them all in varying degrees. In the very large proportion of cases it is the one prominent feature, and varies in its degree from a mild general defect to a completely vegetative condition, where the patient can only follow a certain simple routine requiring the least possible degree of intellection. In the milder form the mental action, though limited, is sufficient to make the patient a useful member of the society in which he finds himself if he is only subjected to the proper control and to judicious general management. These patients do well in asylums, and can do much to make themselves useful; outside of such institutions they are, as a rule, incapable of taking care of themselves. Their condition is, in fact, a more advanced degree of what we have already described as recovery with defect. Sometimes they have a certain tendency to excitement, and are usually classed as

chronic maniacs. In other cases depression is the ruling feature, and they are usually called chronic melancholiacs. Delusions may be present and very marked, likewise hallucinations and illusions, and some of these cases fall under what is called secondary paranoia; and in still other cases mental confusion is marked. In fact, the symptoms are infinitely varied, so that all of these types and some others may be counted in the permanent population of any large institution. The bodily health in these cases may be reasonably good; they are able to work and often are extremely willing and useful; others, again, are absolutely helpless, and their general condition requires the constant attention of the physician, not so much to treat actual illness as to oversee and prevent a general, more rapid decay that would follow from their lack of attention to all the ordinary rules of healthful living. As a rule, the chances of life of these patients are far less than those of the average normal individual. They break down readily in disease and are especially subject to accidental ailments, lung trouble, etc. The average mortality of an asylum which is made up of this class is therefore higher than that of communities in any condition except the most unsanitary. In a wellregulated institution the death-rate can not well be kept under 6 or 7%, and while this higher rate is largely due to deaths in acute insanity, these chronic insane. furnish far more than their share as estimated by the usual ratio of deaths in the general community. Outside of asylums and poorhouses these chronic cases are sometimes found, and with kindly and judicious friends they manage to live a comparatively comfort-. able existence. These cases, however, are exceptional, but the facts of family care of the insane as shown in Belgian and Scotch communities demonstrate how practicable this method of controlling them may be found. It has, however, its disadvantages, and re

quires to be carried out under the best conditions in a stable community where the traditions and customs have been adapted to it from generation to generation. It also requires a thorough and conscientious medical oversight. Violent cases of this type, and there are many such, can be properly cared for only in an asylum, though there are many that suffer miserably in poorhouses and jails.