Oil on the brain: dementia in the popular press prior to the 1906 Alzheimer case report

Concepts of dementia and use of the term go back several hundred years preceding the description published by Alzheimer. Furthermore, the association between age and cognitive decline was already well recognised around 1200 BC.¹ The first use of the word dementia was by the physician Aulus Cornelius Celsus (circa 25 BC–50 AD) in his De Medicina, in 30 AD.² Over the next 2,000 years the term dementia was understood by the general public to have a variety of meanings, and a great number of causes of dementia were theorised. It has been stated that most people—incorrectly—believe that in ancient times, this term was originally related only to insanity.³ French physicians of the late 1700s began to study dementia: Philippe Pinel (1745–1826) distinguished dementia from mania, while his pupil Jean-Étienne-Dominique Esquirol (1772–1840) provided a detailed clinical description of dementia and documented findings from autopsies.

On 3 November 1906, a clinical psychiatrist and neuroanatomist, Alois Alzheimer, reported “a peculiar severe disease process of the cerebral cortex” to the 37th Meeting of South-West German Psychiatrists in Tübingen.⁴ It excited little interest despite an enthusiastic response from Emil Kraepelin, who promptly included “Alzheimer’s disease” in the third edition of his text Psychiatrie in 1910. Over the next 100 years, Alzheimer’s disease became a household name and revolutionised the way we conceptualise dementia.

The American Psychiatric Association sought to publish a glossary for mental disorders in 1952 in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), with the DSM-5 being published in 2013. In the DSM‑5, a cluster of neurocognitive disorders is characterised by the presence of cognitive deficits that are the most prominent and defining features of a given condition. The disorders in the neurocognitive cluster are also characterised by “acquired” deficits, which represent a decline from a previously attained level of functioning and are not neurodevelopmental deficits present from birth or early life.⁵ These advances in the classification of neuropsychiatric disorders have bypassed the more commonly used umbrella term dementia, from the Latin words de, or “without”, and mens, or “mind”, which join together to mean “madness”. Dementia has usually been defined as a term for several diseases that affect memory, thinking and the ability to perform daily activities. It mainly affects older people. While consciousness is not affected, the impairment in cognitive function is commonly accompanied, and occasionally preceded, by changes in mood, emotional control, behaviour or motivation.⁶

We sought to identify and classify the various uses of the term dementia in the media or popular press in the nineteenth century, prior to Alzheimer’s case report.

Methods

Papers Past is a project of the National Library of New Zealand that aims to digitise all newspapers, magazines, selected letters and diaries and parliamentary.⁷ There are 96,022,840 newspaper articles in this dataset delivered as digitised full-text PDF files; these articles date back as far as 1839. The dataset employs a search-by-keyword function, with search filters being dates, title and content type.

We searched the Papers Past dataset for newspaper articles in which the term dementia was included in the title or content for the period 1839–1906.

Articles were included in the final analysis if they mentioned descriptions, causes and treatments of dementia. In the case of duplicate publications or republished articles, only the article published first was analysed. We excluded articles in which the term dementia was used as a derogatory term implying a degree of impairment outside of the clinical context. An example of the use of dementia in a derogatory context is: “Our new picture gallery led to a dispersion of the ‘national’ collection. I wonder what dementia has seized on this fragment of a community … to call its possessions ‘national’?”⁸

All statistics are descriptive.

Compliance with ethical standards

Following consultation with the ethics committee of the University of Otago, it was decreed that ethical review and approval was not necessary as all sources were from publicly available newspaper articles.

Results

There were 1,521 newspaper articles between 1839 and 1906 in which the word dementia was identified in the content or title. Of these, 165 met the inclusion criteria. The majority of reports excluded were for the following reason: dementia was used as a derogatory term in the context of political or financial newspaper reports. Of the 165 reports of dementia included, 87 had a description of the condition, 92 mentioned a cause of dementia and 25 included a description of management. Categories were not mutually exclusive. In addition, one report included statistics, presenting a table of discharges and deaths from Mount View Asylum during 1874–1875, which showed that 15 of 23 patients were diagnosed with dementia.⁹

Description

Most descriptions given in the newspaper articles were rich in information but did not specifically emphasise medical terms or relevance. Articles often included descriptions of physical condition or behaviors that were then attributed to dementia, including imbecility, clumsy jestering, confused memory, difficulty in articulation, violence, destructive behaviour and wandering. Examples include: “…and reported that the unfortunate man George Halliwell, ex-linesman in the Telegraph Department, who has been missing for over a fortnight, has been wandering about the bush beyond Kerikeri, and that he was suffering from dementia…”;¹⁰ “A tragedy is reported from … Mrs Moylen wife of local publican in a fit of dementia attacked her 2 children with a hammer battering in their skulls … the woman escaped to the bush and has not yet been found.”;¹¹ “…the signs of their dementia being only visible now and again in the course of their conversation … Mrs McGrath holds her firm conviction of being an angel of high degree…”¹²

Causes

The cited causes of dementia in the reviewed articles are: brain injury (N=13); physical injury (N=7); old age (N=12); environmental factors (N=34); alcohol and drug use (N=26); mental and emotional pressure (N=14); mental impairment (N=44); religion (N=8); and other (N=2).

The most common cause of dementia described in the reviewed articles was mental impairment (N=44), with special emphasis on mania, post-partum depression and intellectual disability. This was followed by environmental factors (N=34). Environmental factors as a cause for dementia included: living and working conditions on the goldfields, such as foul air when working underground or bad water, gas arising from bore holes, sunstroke, noise, malnutrition and the loneliness of miners known as “hatters”.^13–15 The term hatter was used in Australia and New Zealand during the gold rush era to describe a miner who worked alone, rather than in a partnership or mining party. The most commonly accepted explanation is that a solitary miner would often keep his gold hidden in his hat. Because he had no partners with whom to share his earnings, he could conceal his gold dust or nuggets in the lining of his hat, leading to the nickname hatter.¹⁵

Management

The most common form of management for dementia was incarceration, either within an asylum or a gaol, occurring in 18 of 25 reported cases. One report, however, mentioned that dementia could be managed at home, and another that dementia could be cured; neither report provided any further details. Five reports mentioned specific treatments for dementia. These included: a blister to the neck;¹⁶ Dr S’s Rheumatic Balsam taken internally twice a day, which was recommended by a medium during a séance;¹⁷ milk with lime water;¹⁸ the administration of marine serum, after which “general improvement was great”;¹⁹ and cranial surgery, recommended by a well-known London specialist who wrote that “in well-chosen cases of dementia [it] is the only scientific treatment”.²⁰

Discussion

Papers Past is a project of the National Library of New Zealand that provides a unique opportunity to explore descriptions, causes and treatment of dementia reported in the media or popular press in New Zealand in the nineteenth century, prior to Alzheimer’s case report.

In the present study, the descriptions given in the newspaper articles are far from being of clinical structure. The clinical description of dementia often encompasses medical technical terms pertinent to general pathophysiology. Most clinical descriptions rely on defining features that enumerate the typical signs, symptoms or defining patient features essentially describing memory impairment, language impairment, functional difficulties and personality changes. While rich in information, most descriptions given in the newspaper articles did not specifically emphasise medical terms or relevance but rather focussed on behaviours that were ascribed to dementia. Without further information we can only speculate that some behaviours described, such as wandering behaviour, visuospatial impairment and aggression, may be associated with dementia. At times, however, the behaviours described are clearly not part of our current understanding of behavioural disturbances associated with dementia. One example is: “The woman Ryan is said to be suffering from dementia, the results of sunstroke, which is said to induce recurrent fits, during one of which she cut her hand.”²¹

While old age was reported as a direct cause of dementia in 12 newspaper articles, potentially reflecting that dementia mainly affects older people, many cases of dementia reported in the newspaper articles occurred in younger adults, and were attributed to mental impairment such as postpartum depression. This aligns with concepts widely accepted in the Western world at the time. In the eighteenth century, the disorder was described as “madness or melancholia”, but towards the end of that century, dementia started to be considered a disease of the brain. The physicians Philippe Pinel and Jean-Étienne-Dominique Esquirol observed that dementia resulted in “brain diseases” causing the person to “lose joyfulness”.²²

Dementia was attributed to a variety of environmental factors, some of which reflect specific New Zealand conditions, such as those experienced during the main gold rushes that occurred between the 1850s and 1870s. This somewhat reflects the situation in other countries, such as Australia and the United States of America, where some individuals working on the goldfields experienced mental illness, and where heavy alcohol consumption, boom town pubs and disorder in mining settlements were common.¹³

Alcohol was the third most common cause of dementia mentioned in the newspaper articles. This is consistent with modern research that shows alcohol is gaining increased recognition as a risk factor for dementia, with chronic, heavy alcohol use causing alcohol-related brain damage.²³ However, in some of the newspaper cases, dementia was likely used to describe the short-term cognitive impairment associated with excessive alcohol consumption rather than the cognitive deficits in later life attributed to long-term alcohol use. At the time, alcohol use was extensive within New Zealand. Frontier conditions, whereby there was an excess of unmarried men often living in tents and shacks, made alcohol attractive, with pubs offering warmth, news and company.²⁴ There was a high level of binge drinking, with many men in frontier jobs coming into town when they were paid and going on drinking sprees that could last for days, with drunken behaviours being highly visible and socially disruptive. Indeed, convictions for drunkenness in New Zealand at the time were more numerous than in the United Kingdom per head of population, with more than 18 convictions for drunkenness for every 1,000 people, increasing to more than 28 in 1864 during the gold rushes. Of 114,146 convictions from 1855–1870, 51,110 were for drunkenness.¹⁴

The most common form of management for dementia was incarceration, either within an asylum or a gaol. This is not surprising given that the condition was not recognised as a distinct pathological disease until the twentieth century and was often classified as “madness” or “senility”.²⁵ In the nineteenth and early twentieth centuries with family and community care structures weakened, state-funded asylums were established to house the “insane”. In New Zealand, the Lunatics Ordinance 1846 decreed that a “lunatic”, certified by two doctors, could be held in a gaol or other prison, or in a public hospital or asylum. New Zealand adopted the prevailing English system of institutional care, with the establishment of small purpose-built asylums on the edge of provincial capitals in the 1860s and 1870s, and later much larger institutions, such as Seacliff near Dunedin (1879), and Porirua near Wellington (1887).⁹

One limitation of the current study is that the Papers Past project necessarily privileges written Pākehā views over oral Māori views and thus does not capture all understandings of dementia in New Zealand during the period studied. The only article wherein Māori are mentioned states: “The Maoris seem to be mentally a healthier race than our own. This is possibly due to their leading a more primitive life and thus escaping those cares and exciting causes that first lead to mental worry and subsequently to dementia of one kind or another.”²⁶ In general, historically there has been very little literature covering Māori understanding of dementia, although this is becoming more understood through the work of Dr Margaret (Makarena) Dudley and colleagues.²⁷ Their research describes Māori understandings of the ageing brain, and dementia in particular. Mate wareware (becoming forgetful and unwell) affects the wairua (the spiritual dimension of Māori). This cultural concept clearly positions the importance of using te reo Māori (the Māori language) and is underpinned by mātauranga Māori.²⁸

A second limitation is how well do these New Zealand views compare with other contemporaneous views, especially in Europe? A comparison can be made with a recent essay published in the Lancet Neurology, wherein the author began by describing the fear that the words dementia and Alzheimer’s disease can elicit: “The spectre of Alzheimer's or dementia is like a cough in a Victorian novel, a harbinger of death.”²² The article further describes a process not dissimilar to our findings: “In the 18th century, the disorder was described as ‘madness or melancholia’, but towards the end of that century, dementia started to be considered a disease of the brain...”²²

The Papers Past project has provided some insight into the descriptions, causes and treatment of dementia in the nineteenth and early twentieth century in New Zealand, prior to Alzheimer’s case report. While the newspaper articles were often limited with regards to the amount of information provided on the cases of dementia, it appears that descriptions of the condition generally aligned with Western concepts at the time, with dementia described as madness or melancholia, and that the causes and treatment of dementia reflected the New Zealand environment and Pākehā culture during colonial times. This resource may provide a potential primary source of the exploration of other medical topics that have captured the awareness of the general public.