#5 ºf . * ,
Series I 1912
Westborough
State Hospital Papers
A Testimonial to
GEORGE SMITH ADAMS, M. D.
Edited by
SOLOMON C. FULLER, M, D.
(Reprinted from New England Medical Gazette
Vol. XLVII pp. 467-686)
by W. S.
77) 4-
S 3

Series I 1912
Westborough
State Hospital Papers
A Testimonial to
GEORGE SMITH ADAMS, M. D.
Edited by
SOLOMON C. FULLER, M. D.
(Reprinted from AVew England Medical Gazette
Vol. XZ VII pp. 467-686)
BOSTON
THE ARAKELY AN PRESS
368 Congress Street
Westborough State Hospital
Westboro, Mass., Sept. 15, 1912.
The papers published in this book have been prepared by
members of the medical staff of Westborough State Hospital
during the past eighteen months. Two of the contributions, III
A Study of the Miliary Plaques Found In Brains of the Aged by
Dr. Fuller and XIV Further Observations on Alzheimer’s Disease
by Drs. Fuller and Klopp, were first published in the American
Journal of Insanity for October, 1911, and July, 1912, respectively.
XIII, Alzheimer's Disease (Seninm Praecox): The Report of a
Case and Review of Published Cases, first appeared in the Journal
of Nervous and Mental Disease for July and August, 1912. The
remaining papers are here printed for the first time. Two other
papers published during the year have not been included. One
of these by Drs. Fuller and Klopp dealt with data collected
originally for the 1910 Manic-Depressive Symposium of the New
England Society of Psychiarty and concerned one hundred and
twenty-nine cases which had been diagnosed as Melancholia of
Involution during a period of six years at this hospital. This
paper was further elaborated and presented at the 1911 meeting
of the Neurological Society, in the proceedings of which it was
published, January, 1912. The other paper, not here collected,
Ein Fall der Alzheimerschen Krankheit by Dr. Fuller, was published in
The Zeitschr, f. d, gesamte Neurologie u Psychiartrie for July 31, 1912.
It is the present purpose to publish from time to time, as
material warrants, further series of Westborough State Hospital
Papers.
H. O. SPALDING, M. D.
Superintendent
Westborough State Hospital.
Institutions receiving this book will please make acknowl-
edgement to the editor, Dr. S. C. Fuller, Box 288, Westborough,
Mass., and inform him if they wish their names put on the mail-
ing list for future books.
s;
ADAMS, M.D.
GEORGE SMITH TO
*
LATE SUPERINTENDENT OF WESTBOROUGH STATE HOSPITAL
AND SOMETIME LECTURER ON CLINICAL PSYCHIATRY
AT BOSTON UNIVERSITY SCHOOL OF MEDICINE
THESE PAPERS ARE DEDICATED BY HIS FORMER ASSISTANTS
AND PUPILS ASSA TOKEN OF THEIR REGARD AND IN
HONOR OF TWENTY-FIVE YEARS SERVICE
ON THE MEDICAL STAFF
WESTBOROUGH STATE HOSPITAL.
Tº, A ea
ERRATA.
Page 114, tenth line of second paragraph for abnorminal read ab-
dominal.
Page 118, nineteenth line from top for pleose read please, and trans-
pose lines 27 and 28.
Page 123, second line from top for chromatilysis read chromatoly-
sis, and seventh line for chromatlytic read chromatolytic.
Page 124, eleventh line from bottom for “quasi systemtic” read
“quasi systemic.”
Page 125, tenth line from top for (inchsinophile granules) read
(fuchsinophile granules).
Page 145, sixth line from bottom for paralytica read averages.
Page 167, twentieth line from top for the red nuclei rubrum read
the red nuclei.
Wherever fuchsin-light green appears read acid fuchsin-light
green.
II.
III.
IV.
VI.
VII.
VIII.
CONTENTS
GEORGE SMITH ADAMs......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
THE PSYCHOPATHIC DIVISION WESTBOROUGH STATE HOSPITAL.
By HENRY I. KLOPP, M.D., ALLENTown, PA., Superintendent,
Allentown State Hospital; Formerly Assistant Superintendent
and Physician in Charge of Psychopathic Division, West-
borough State Hospital.... . . . . . . . . . . . . . . . . . . . . eszele-e e s e e s > * *
A STUDY OF THE MILIARY PLAQUES FOUND IN BRAINS OF THE
AGED. BY SOLOMON. C. FULLER, M.D., Pathologist, West-
borough State Hospital and Instructor in Normal and
Pathological Anatomy of the Central Nervous System, Depart-
ment of Neurology, Boston University School of Medicine.
(Plates I-XVI.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RECOVERIES IN DEMENTIA PRAECox. BY WILLIAM W. Coles,
M.D., KEENE, N. H., Formerly Senior Assistant Physician,
Westborough State Hospital... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
THE SELECTION OF STIMULUS WORDS FOR EXPERIMENTS IN
CHANCE WORD REACTION. BY ELEANOR A. McC. GAMBLE,
PH.D., Professor of Psychology, Wellesley College, AND
ALBERTA S. GUIBORD, M.D., Physician, Neurological Depart-
ment, Evans Memorial for Clinical Research; Formerly
Senior Assistant Physician, Westborough State Hospital.....
Two CASEs OF MULTIPLE SCLEROSIs witH OBSCURE NEUROLOGICAL
AND MENTAL SYMPTOMs (FORMES FRUSTEs). BY SOLOMON C.
FULLER, M.D., HENRY I. KLOPP, M.D., AND MICHAEL M. JoRDAN,
M.D., Assistant Superintendent, Westborough State Hospital.
(Plates XVII-XXVI.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SLEEP AND SOMNAMBULISM. (Authorized Translation from the
French of PROF. M. BERN HEIM, Nancy, France.) BY WILLIAM
PURULENT STREPTOCOCCIC CEREBRO-SPINAL MENINGITIS FROM
MIDDLE EAR DISEASE: THE REPORT of A CASE. By RUTH B.
CoLES, M.D., KEENE, N. H., Formerly Senior Assistant
Physician, Westborough State Hospital, AND SOLOMON C.
FULLER, M.D. (Plates XXVII-XXIX.) . . . . . . . . . . . . . . . . . . . . .
II
IQ
77
QI
III
I29
I37
CONTENTS
PAGE
IX. BRAIN WEIGHTS IN PsychoSEs, BY STELLA. B. SHUTE, A.B.,
Assistant in Histology, Westborough State Hospital.......... I45
X. A REPORT on THE THERAPEUTIC USE OF BACTERIAL VACCINES
AND ON ANTI-TYPHOID VACCINATION AT WESTBOROUGH STATE
HospitaL. BY CLARENCE C. BURLINGAME, M.D., FERGUs FALLs,
MINN., Assistant Superintendent, Fergus Falls State Hospital;
Formerly Senior Assistant Physician, Westborough State
Hospital. ................................................... I5I
XI. A CASE OF MULTIPLE PAPILLoMA of THE BRAIN (ADENo
CARCINOMA). BY SoLoMon C. FULLER, M.D. (Plates XXX-
XXXII.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I6I
XII. A CASE OF MONGOLIAN IDIOCY. By WALTER A. JILLson, M.D.,
Senior Assistant Physician, Westborough State Hospital.
(Plates XXXIII-XXXIV.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I71
XIII. ALZHEIMER's DISEASE (SENIUM PRAEcox): THE REPORT OF A
CASE AND REVIEW OF PUBLISHED CASEs. BY SOLOMON C.
FULLER, M.D. (Plates XXXV-XXXVIII.). . . . . . . . . . . . . . . . . . I75
XIV. FURTHER OBSERVATIONS ON Alzheimer's DISEASE. By SoLoMon
C. FULLER, M.D., AND HENRY I. KLoPP, M.D. (Plates XXXIX-
XLI.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
XV. A CASE of HUNTINGDON’s CHOREA witH LATE ONSET. By
SOLOMON. C. FULLER, M.D., AND JoHN F. LovELL, M.D., Senior
Assistant Physician, Westborough State Hospital. (Plates
XLII-XLV.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2I9
I
GEORGE SMITH ADAMS.
The former assistants of Dr. George Smith Adams, for twenty
years superintendent and for more than a quarter century con-
tinuously on the medical staff of Westborough State Hospital, have
united in the series of papers here collected to commemorate his
long and worthy service. As medical students at Boston University,
where during the past twenty years he has given clinical demonstra-
tions in mental diseases, the majority of the contributors to this vol-
ume received their first instruction in clinical psychiatry from Dr.
Adams. Later, a larger majority of us, as his assistants at West-
borough and through the daily staff conference over which he pre-
sided, obtained our first real appreciation of some of the greater
problems of psychiatry. And all of us, in every effort for better
treatment and extension of our knowledge of the cases at West-
borough in whose care we assisted, unfailingly received his
heartiest support and encouragement. To each the great inspiring
feature of the man has been that, despite the multifarious executive
details of the superintendency, Dr. Adams remained the physician—
no phase of psychiatry, alone or in its relation to general medicine,
was without appeal to him. This broad interest engendered in the
staff an enthusiasm for the special work we were called upon to per-
form, and whatever of success may have been ours is due in large
measure to his teachings and the inspiration of his example.
The contributors, therefore, on the occasion of Dr. Adams’ re-
tirement from the superintendency of Westborough State Hospital,
offer these papers as a mark of their appreciation of the man and
physician, and also in recognition of his ability as an hospital ad-
ministrator. We believe that he fits well in the class of which Ex-
president Work of the American Medico-Psychological Association
writes, “In the physical care of the congregated sick . . . masters in
medicine.”
The estimate placed on Dr. Adams’ work by the trustees of
Westborough State Hospital is shown in the following quotation
from the annual report for the year ending Nov. 30, 1911 : “It has
been the policy of the trustees to develop this institution just as far
as practical along hospital rather than asylum lines. Classification
of patients has been made and the most modern methods of treat-
ment introduced in the effort to cure the largest number of cases
where such an outcome seemed at all possible.
“The trustees feel that their efforts in this direction have met
with a very appreciable measure of success, but at the same time
8
they recognize fully that whatever creditable results have been ob-
tained are due very largely to the indefatigable work, personal in-
terest and skill of the superintendent during most of the life of the
hospital. . . . . The trustees feel that it is but just and right at this
time to acknowledge publicly their recognition and grateful appre-
ciation of the many years of loyalty and devotion on the part of Dr.
Adams.” *
And again, upon the resignation of Dr. Adams the following
appreciation was spread upon their records and a copy sent to him:
“In accepting the resignation of Dr. George S. Adams as Super-
intendent of Westborough State Hospital, its trustees would ex-
press their appreciation of his long and constant devotion to its in-
terestS.
“During the twenty-five years of this service, the work and re-
sponsibility have increased two-fold, to be met and borne by
Strength and ability equal to the demand.
“The general harmony of the hospital-administration in the
past years is recognized as due to the relations, official and per-
sonal, which have been established and maintained under sympa-
thetic leadership. Among the institutions of this Commonwealth
this hospital may justly claim high place, and it is gratefully re-
corded that to him who has come with it all the way hither, is the
satisfaction and the reward.”
George Smith Adams was born of Scottish parentage at Nor-
wich, Conn., February 7th, 1848. When he was three years of age
his parents moved to Massachusetts, where the greater part of his
life has been spent. w
At the outbreak of the Civil War, our subject was a
boy of fourteen. His father and an elder brother enlisting in the
Union Army made it necessary for him to leave the public school
to aid in the support of the family left behind. From this time on, his
formal education in the schools ceased until he was twenty-five,
when he began the study of medicine. After leaving the public
school, he learned the trade of machinist, attending meanwhile the
night school of that period. Notwithstanding this handicap in his
preparatory training, he obtained a good and serviceable education
which all in all proved a good foundation for the study of medicine,
for his studies had been well directed. His general reading had
brought an acquaintance with much of the best in English litera-
ture; he possessed a practical understanding of applied physics and
a good knowledge of the principles of biology. . Later in life his in-
terest in these things did not wane, particularly in those sciences
closely allied to medicine. This is well evidenced in his wide knowl-
edge of botany and in his good grasp of present-day general bio-
logical problems.
9.
At the age of twenty-five George Smith Adams entered Hahne-
mann Medical College, Philadelphia, Pa., graduating in 1876, first
in a class of fifty-four, winner of the Centennial gold medal for
general excellence throughout the course, previously winner of a
bronze and silver medal for good work. After graduation Dr.
Adams practiced in Philadelphia for a year. The following year
was spent at Wilmington, North Carolina. He then went to May-
nard, Massachusetts, his boyhood town, where he was a general
practitioner from 1878 to 1881. Moving to Worcester, Massa-
chusetts, he practiced there for the next five years, and it was there
he received his appointment as first assistant physician to Dr. N.
Emmons Paine, first superintendent of Westborough State Hospital.
Dr. Adams' service at Westborough State Hospital began De-
cember 13th, 1886, coincident with the opening of the Hospital for
the reception of patients, and continued to May 21st, 1912. Upon
the resignation of Dr. Paine, in 1891, Dr. Adams was promoted to
the superintendency, a position which for over twenty years he
administered with great ability. The policy instituted at the very
opening of the Hospital, namely, a strictly hospital attitude towards
patients, rather than asylum with inmates who were to be prevented
from doing injury to themselves or others—merely a custodial in-
stitution—was rigidly followed throughout his administration. He
passed on to his successor an institution for the care and treatment
of the insane where the “hospital idea” was not simply a hoary tradi-
tion brought out and furbished for special occasions, but an ideal
which for twenty-five years had been constantly held before its
officers and minor employees as something toward which every ef-
fort must be bent.
The present organization of Westborough State Hospital owes
much to Dr. Adams. There are many features which might be
singled out for mention, but we limit comment to the most important
of his larger policies. First and foremost of the achievements of the
Hospital is the Psychopathic Division, the evolution of which is
described in one of the contributions to this volume. For several
years, Dr. Adams had warmly advocated the segregation of the
acute hopeful cases from the chronic and dementing cases. The first
fruit of this campaign was the Talbot building around which has.
been developed a group of buildings, their main object to provide
proper facilities to hasten as quickly, as is consistent with safety,
the restoration to mental and physical health of those cases that will
get well. The group makes no pretense at being a psychiatric clinic,
but it is a place where therapeutic measures are cultivated assidu-
ously. Out of the success of these special hospital buildings have
grown two other groups, of the nature of colonies, for the quiet,
able-bodied, harmless insane. It should be borne in mind that the
IO
beginning of these attempts at segregation, at least for the first men-
tioned group, goes back some fifteen years, so that, when the broad
policy of the State Board of Insanity was instituted with reference
to hospital, asylum and colony groups of patients, Westborough
State Hospital was in position to seize the opportunity to demon-
strate that these classes, even though on a small scale, could be cared
for efficiently in a single institution.
Of Dr. Adams' medical interest we have already spoken, but
we would mention what has always seemed to us most remarkable,
his intimate knowledge of the hospital details, of patients and their
symptoms, even after years, and his emphasis on the personal note
in the relation of patient and physician—a patient to him was some-
thing more than a case. He knew practically every patient by name
and kept in close touch with the progress of their condition.
It is hoped that freedom from the annoyances of adminis-
trative details will bring the opportunity for elaboration of his views
on the treatment of the insane; and that his rich experiences will
find some permanent record for the benefit of his co-workers in this
important field of medicine. *
S. C. FULLER.
WESTBOROUGH STATE HOSPITAL,
Agust IOth, I9I2.
II
A
THE PSYCHOPATHIC DIVISION, WESTBOROUGH STATE
HOSPITAL.
By HENRY I. KLOPP, M.D.
The evolution of State supervision and hospital treatment
of the insane may, as has been aptly said, be divided into three
periods:
I. The chain and dungeon era.
II. Asylum era.
III. Era of hospitals—psychopathic divisions for acute cases,
colonies for the chronic.
Definite dates for their separation cannot be fixed in the na-
ture of the case, but the last period commences at a comparatively
recent date. It has seen a marked advance not only in mere mat-
ters of housing and the temporal welfare of these unfortunates but
also in the methods employed in their treatment, as well as in our
knowledge of the medical and social problems involved. The mod-
ern insane hospital is more than a custodial institution; it is a hos-
pital in every sense of the word where each patient receives special
consideration and where every effort is made to return him to So-
ciety either as a normal individual, or as capable of adapting him-
self in a fair degree to his surroundings. Failing this he is to be
made as useful as possible within the institution.
From the standpoint of the hospital grouping, the insane in
the public institutions of Massachusetts are classified in three
main divisions: (1) the acute and curable, for which a strictly hos-
pital care is advocated, (2) the chronic insane who require strict
supervision and confinement for the protection of themselves and
the public—the asylum class—and (3) the chronic but able bodied,
harmless insane, who are either competent or may be taught to do
some useful work to aid in their support, allowed a larger liberty
and placed under surroundings more homelike than would be ad-
visable for the first two classes—the colony group.
According to the present idea this grouping can be made
to economic advantage in a single institution under one adminis-
trative head, and the Westborough State Hospital offers an ex-
ample of such management.
This paper will deal with the acute and curable insane, the
first of the classes just mentioned. Their treatment requires first
and foremost a special organization, one in many respects similar
to that of a well organized general hospital; its medical officers en-
thusiastic and efficient, its nursing corp intelligent and adequate in
I2
number. Improved therapeutic apparatus and accommodations for
proper grouping of the cases must be liberally provided, for the
therapeutic requirements are quite often like those for acute
somatic diseases. Indeed, anyone who is familiar with work
among the insane will not be astonished at the statement that
the treatment of the ordinary ills to which flesh is heir forms
no small part of the staff's daily routine. In addition to these gen-
eral hospital features must come, of course, the special facilities
which mental disease of this character require. Here it may be
said in passing the costly and elaborate are not always the most
efficacious in the treatment of the insane. But it must not be
understood that a measure if beneficial should be ruled out solely
on the ground of cost, nor that wards and buildings to be useful
must perforce be ugly and shoddy. t
At Westborough, the Talbot building, opened in 1898, formed
the nucleus of the psychopathic department. It is a two-story
building accommodating sixty patients, equally divided between
the two sexes. The wings for the two sexes are separated by a
group of rooms and suites for physicians and minor officials,
rooms for electrical treatment, and examining rooms which
occupy the central portion of the building. On the upper floor of
each side are three single rooms for patients, a dormitory of
twenty beds, a dining-room and serving-room, bath and spray
room, linen rooms and clothes rooms. On the first floor are a
large living room, Sewing room, bath, spray and examining Offices,
two single rooms, one double room and a dormitory of four beds.
The need for such a building was conceived and urged by
Dr. George S. Adams in 1896, the original purpose being the
isolation of quiet and seemingly hopeful cases. Its success was
immediate. Patients from the old hospital group who were sent
to Talbot looked upon this transfer as the preliminary step toward
home. Indeed, not only to patients did Talbot mean much,
for it also brought a new spirit into the whole medical life of the
hospital, a spirit that only those who were there before and after
the movement began can ever fully appreciate.
It had been long the common experience of psychiatrists
that disturbed states of the insane were not necessarily of bad
prognostic import; that many patients who enter the hospital
greatly excited, depressed or confused were oftentimes the very
cases from which the most in the way of restoration to mental
health was to be expected. In fact it was not long after the open-
ing of Talbot that a large number of the patients treated there
had come from this originally very disturbed class. Furthermore,
the building afforded opportunity for the treatment of the cases
iI3
coming voluntarily to the Hospital who would naturally have
hesitated to place themselves of their own free will in surroundings
which have long been an object of horror to the public. Many
of these were borderline cases, or those suffering from psychas-
thenia or neurasthenia, on whom the effect of the old environment
would be but the opposite of favorable.
But it became immediately apparent that the acute hopeful
cases needed isolation even more during their markedly excited
or depressed periods, and in 1903 certain wards in the asylum
group were set aside for this purpose, affording accommodations
for the acutely excited or depressed, those suffering from the con-
fusional states of psychoses of recent onset, the acute alcoholic
insanities and drug habitues which were most likely to be
benefited. *
The inadequate facilities of these wards and the general over-
crowding in this part of the Hospital made it impossible, under
such arrangements, to care for these patients to the best advantage.
It was plain that suitable buildings must be constructed. In 1905,
accordingly, the Codman building, with a capacity for forty-four
women was opened, and continued to be used for women until
1910, when the Childs building with a sixty-bed capacity was ready
for the reception of patients. The women were then transferred to
this new building, certain improvements made in Codman which
experience had suggested, and the building turned over to men of
the same class as of the women who had been moved.
Codman is a building of two stories. On each floor there
are three dormitories, two of which have a capacity of seven beds
each, the other of three beds, five single rooms for patients, one
serving-room for food, an examining room and an adequate linen
room. On the second floor there is a room for the continuous
bath provided with four tubs, a spray bath and toilet facilities, on
the first floor three tubs for the continuous bath and also a
spray and apparatus for electrical treatments. Leading from each
floor is a spacious, covered veranda, measuring thirty by thirty
feet, where beds and reclining couches may be placed. The
verandas are screened. ë
The Childs building is also a two-story structure, and is a
slight modification of Codman. There is an annex extending from
the central portion of the rear of the buildng, on the second floor
of which are rooms for hydrotherapy, a room for the continuous
bath with filve tubs and a room containing apparatus for various
sprays and douches, a single room and two three-bedded dormi-
tories for very disturbed patients and a room for electrical treat-
ments equipped with high frequency and X-Ray apparatus, gal-
I4.
vanic and faradic cabinets with sinuosidal attachments, a leuco-
descent lamp, and a reclining electric light cabinet. On the first
floor of the annex there is a bath room with three tubs for the con-
tinuous baths, and a spray, two single rooms, three dormitories of
three beds each and a room for electrical treatments. On each
floor of the main part of this building there are two seven bedded
dormitories, six single rooms, an examining room, a nurses’ record
room, a serving room, a dining room for nurses, a day room for
patients, linen room and toilet facilities. From the southerly end
of the main building, as with Codman, there are two covered
verandas, thirty by thirty feet, the upper one screened. On the up-
per veranda are twenty beds and a few steamer chairs. Here
patients who are not noisy and do not show too great unrest are
cared for day and night, while the first floor veranda is provided
with an equal number of reclining couches and steamer chairs
which are used chiefly for outdoor airing during the day.
The upper floors of these two buildings Codman and Childs,
serve as the receiving wards for the disturbed cases of this group,
and such other disturbed cases admitted to the hospital, concerning
which there is any doubt as to whether or not they may be con-
sidered as hopeful, are also received and kept here until all reason-
able doubt as to non-suitability has been dispelled. The patients on
the upper floors are essentially bed patients. As a matter of fact a
preliminary treatment of rest in bed is considered of such impor-
tance that all admissions whether to these two buildings or to Tal-
bot are given rest-in-bed periods of varying length. Moreover, the
patient is more carefully and regularly observed in bed than other-
wise, food is better taken and acute mental symptoms abate more
quickly. On these upper floors the patients remain during the
stormy and distressing period of their psychosis.
For certain maniacal conditions, as well as for certain states
of restlessness, agitation and depression, the so-called neutral
bath which has been used here extensively during the past ten.
years, has proven a most satisfactory sedative in allaying excite-
ment and in controlling depression. These baths are prolonged
from two to three hours to one to two days, and in extreme cases,
two to three weeks, the patients always under the constant super-
vision of a nurse. The optimum temperature for these baths is 96
F., the lowest range should not go below 92 F., nor the highest
above 97 F., mid-summer optimum 94 F. Of course, during baths
of any length the patient takes his meals as well as sleeps in the tub.
Warm packs are also extensively employed, especially in cases
with excitement and marked psycho-motor unrest, where it is not
only difficult to secure the full benefit of the continuous bath but
I5
also where, for various reasons, such a procedure would be unwise.
These packs are always changed after three hours, and after their
removal, in order to bring about a proper reaction, a cold Sponge
or spray is given. Various shower baths and douches are em-
ployed where conditions seem to indicate, usually in graduated
temperature and force, for their tonic effect. Electric light baths
have seemed of benefit in promoting elimination.
The feeding of patients is considered of the greatest impor-
tance, for many of them on admission show every evidence of mal-
nutrition, which is sometimes the result of defective metabolism
or poor assimilation and sometimes the result of starvation from
refusal of food, induced by hallucinations and delusions. More-
over, almost all cases, whether poorly nourished or not, exhibit
considerable anorexia. So, unless definitely contraindicated,
these patients are not only given and urged to take the usual three
meals, but lunches consisting of broth, milk, egg-noggs and other
nutritious liquids are given between meals. The position is taken
in this matter, and it is abundantly borne out in experience, that
there can be little or no mental improvement without a good physi-
cal constitution upon which to work.
Next in importance to rest, feeding and hydrotherapy, is the
open-air treatment, and to this end the verandas of Codman and
Childs and the lawn and shade of trees in the front of Talbot are
employed. The seasons of the year make no difference. It is felt
that the open air promotes sleep, appetite and assimilation, all of
which are to be desired, and no one can deny the benefit which
comes from better oxygenation. At any rate, when the treat-
ment of these cases is supplemented by the bracing out-of-door
atmosphere, improvement is certainly more rapid than in those
cases in which for various reasons one cannot resort to this
treatment.
When improvement begins—allaying of excitement, abatement
of depression, lessened intensity and frequency of hallucinations
and delusions, or their disappearance, and improvement in general
physical condition, the patient is transferred to the intermediary
wards or rooms on the lower floors of Codman and Childs. If the
patient continues to improve consistently, he is then transferred
to Talbot, where practically all of the convalescent patients have
the freedom of the grounds unattended, and not infrequently two
or more congenial patients are permitted short trips away from
the Hospital, to neighboring villages for outings, or to do a little
Shopping.
In January, IQ08, a small cottage located but a short distance
from the group of buildings already described became available
16
and shortly after was furnished to accommodate eight women, who
live there under surroundings nearly like those of home, as there
is no nurse in charge of the cottage. These patients take their
meals in the Talbot Building. Their ability to hold all they have
gained and to improve further is by no means an unimportant
consideration in deciding upon their complete recovery. With the
beginning of improvement the patients are encouraged to take
an interest in their surroundings. Frequently this interest is
evinced voluntarily by little assistance rendered the nurse, or some
little kindly office to a fellow patient. With continued mental and
physical improvement, and always with the interest of the individu-
al patient in mind, regular employment is permitted and encour-
aged. The men are permitted, for short periods daily, to work in
the various departments of the hospital,—greenhouses, work on
lawns, folding and sorting rooms of laundry, etc. The women as-
sist the nurses in making beds, or in the dining room, work with
raffia, embroidery, knitting, plain sewing and the like. Indoor
games, such as cards, checkers, billiards and the like are encour-
aged. Such as are suitable attend the hospital weekly dance. The
women patients maintain a little club, “The Optimist Club”, to
which they elect their own members. This club gives little enter-
tainments for the patients of this group in the way of concerts,
lectures on topics of interest by outsiders, etc. This is encouraged
because found helpful.
In this progression from one set of wards to another, and from
one building to another, the patient himself more readily appre-
ciates the progress in his case and more willingly cooperates with
the physician and nurses in the measures taken in his behalf.
There is also the added encouragement in seeing patients who
like himself are making progress and he is freed from the depress-
ing influences of the presence of chronic dements, paralytics and
the like. -
While the measures resorted to in the treatment of cases in
the psychopathic division have been outlined in a general way
in what has gone before, it goes without saying no hard and fast
line can be followed in every case. The individual must always be
studied and his peculiar needs met as best as we are able. Even
with drugs these must be prescribed as indicated, even for cases
suffering a like psychosis. When these and other methods fail,
psychotherapy may be helpful and has often so proven. The
cases, therefore, are studied not only from the standpoint as to
where they best fit in the general management of the group but
also from a strictly psychiatric point of view, and upon this latter
the maximum stress that we are able to bring is placed.
17
It has not been proven at Westborough that the isolation of
the hopeful cases and placing them under the sole care of one
physician and his assistant has dulled the psychiatric interest of
the physicians who have the care of the more chronic cases. On
the contrary it is believed to be a stimulus to better work. Indeed
it occasionally happens that patients sent to the services for
chronics, who after a time show conditions which clearly indicate
that they should receive the benefits of the psychopathic division
are more readily spotted, and a certain alertness in accurate ob-
servation is engendered. Moreover, these cases of the psycho-
pathic division are always accessible to other members of the
Staff, and indeed, weekly, the physician in charge is accompanied
on his usual rounds by a number of the staff members who
become acquainted with the progress that is being made in the
various mental conditions. The histories, too, of these cases are
always presented at the staff conference for discussion and diag-
nosis, and not infrequently the patients themselves.
Moreover, these cases of the psychopathic division are always
accessible to other members of the staff, and indeed, weekly, the
physician in charge is accompanied on his usual rounds by a num-
ber of the staff members, who, thus become acquainted with the
progress that is being made in the various mental conditions. The
histories, too, of these cases are always presented at the staff con-
ference for discussion and diagnosis, and not infrequently the
patients themselves.
Three years ago I made a study of the admission to the psy-
chopathic division covering a period of five years, March 1, 1903,
to March I, Igog. During that five-year period, the yearly ad-
missions to this department of the hospital increased 75 per
cent, due in part to our enlarged facilities, in part to a knowledge
of the fact that there was such a department at Westborough
State Hospital and patients or their friends expressing a desire that
they be committed there.
The percentage of this group, the recoverable and those to
whom we had given the benefit of doubt, was to the total ad-
missions during this period 46.31 per cent. Among these were
practically all of the manic depressive cases, involution melan-
cholia, hysteria, exhaustion-infection psychoses, many of the so-
called toxic psychoses and cases of hysteria, and all of the first
admission with recent onset of dementia praecox. We single out
from these cases for special comment here the manic depressive
and dementia praecox groups, the former with a recovery rate
of 70.65 per cent, the latter 20.83 per cent for all forms. It might
be argued that the manic depressive cases would get well without
the advantages of a psychopathic division, and that the cases called
I8
dementia praecox from the fact of their recoveries were faultily
diagnosed. Infallibility in diagnosis is not claimed. And yet
Kraepelin, E. Meyer, K. Kohlbaum, Albrecht, Raecke and Schmid
during 1903 to 1911, inclusive, have reported, on the basis of
katamneses, recoveries varying all the way from 30 per cent, to
2 per cent. It is important to be able to determine what cases of
dementia praecox will get well and to what group belong those
cases which clinically simulate dementia praecox and yet will get
well, but we pass this by since a study of the recovered cases of
dementia praecox cases, by Dr. Coles, is published elsewhere in
this volume. The writer would call attention, however, to a fact
of significance in the service of this department, and that is, that
during the five-year period referred to above, the average hospital
residence of the patients of this group was reduced from 6.76 to
3.47 months, and continues approximately the same. Without
appearing with a brief, this fact alone, if there were not other fea-
tures to recommend, is sufficient to justify the establishment of
similar divisions in the majority of hospitals for the insane.
III
A STUDY OF THE MILIARY PLAQUES FOUND IN BRAINS
OF THE AGED. k
(PLATES I-XVI.)
BY SoLoMon C. FulleR, M. D.
CONTENTS.
I. Introduction.
II. Origin and nature of miliary plaques.
Historical:
Origin from degenerating ganglion cells.
Glial encapsulation of amyloid and other bodies.
Deposited products of pathological metabolism.
Glia rosettes.
| Necrotic foci with proliferation of axis cylinders.
Bacterial nature.
Sphirotrichia multiplex cerebri.
Circumscribed necroses of glial and nervous elements.
An index of senile involution.
III. Material employed and scope of present study.
IV. Analysis of gross findings with reference to plaques.
Atrophic brains.
Normal-weight brains.
Gross lesions resulting from arteriosclerosis.
V. The plaque cases among elderly subjects dying insane.
Clinical abstracts.
Analysis of clinical histories with reference to classification.
Age incidence.
VI. The cases without plaques among elderly subjects dying insane.
Clinical abstracts.
Analysis of clinical histories with reference to classification.
Age incidence.
VII. Material from elderly subjects dying without psychosis.
VIII. Results of examination of material from fifty younger subjects dy-
ing of various mental diseases.
IX. The plaques.
Methods employed for display of plaques.
Their microscopic appearance.
Topographic and stratigraphic distribution.
Relation to glia and vascular apparatus and to nervous elements.
Association with Alzheimer’s intracellular degeneration of neu-
rofibrils.
X. Senile dementia.
General considerations of the histology of normal and patholog-
ical cerebral involution.
Cerebral histology of the plaque cases.
Comparison of general histological changes in non-plaque cases
among elderly subjects dying with and without psychosis.
XI. Summary and conclusions.
* Presented in abstract at the sixty-seventh annual º: the American Medico-Psychologi-
cal Association, Denver, Colo., June 19-22, 1911, and printed here by courtesy of the Association.
2O
I. INTRODUCTION
Although miliary Sclerosis of senile brains was reported by
Redlich more than twelve years ago, and Blocq and Marinesco
even six years prior had called attention to a like condition in
two aged subjects, one of which was an epileptic, the literature
of the structures discussed in this paper is not extensive. Within
the last three years, however, so-called plaques, now recognized
as identical with the miliary sclerosis of Redlich and common
though not constant findings in the brains of persons dying at
an advanced age, have been studied intensively and with illuminat-
ing results. While many interesting details concerning miliary
plaques of the brain have been established, the last word, per-
haps, has not been said. As to the origin and nature of these
miliary plaques, opinions differ, some even taking on the character
of polemics.
Psychoses occurring in the period of senium have received
less attention from the clinicians and anatomists than some other
psychoses with equally unfavorable prognosis, as an example,
general paresis, and are consequently less understood. Compara-
tively little study has been devoted to senile cases largely for
the reason of a commonly expected fatal outcome in a mental
disease affecting persons already near the end of the allotted span
of life. It has been the object of this paper to add to already
existing clinical and anatomical data, data of such character
which when sufficiently accumulated and properly correlated may
serve to explain many obscure clinical states and aid in estab-
lishing a more definite histopathology for the types of involution
psychoses. To this end material from thirty-three elderly subjects
dying insane has been employed for study. By way of comparison
brain tissue from six elderly persons dying without psychosis and
sections from the brain and spinal cord obtained from fifty younger
subjects dying of various mental diseases have been added. The
material from elderly persons dying without psychosis was kindly
furnished by Dr. F. B. Mallory from the autopsies of Boston
City Hospital for the years 1909 and 1910. The remaining
subjects came to autopsy at Westborough State Hospital; the
thirty-three elderly persons, with the exception of two cases in
which plaques were demonstrated in sections prepared five
years ago, died during 1909-1910 and the first three months
of 1911, while the fifty younger subjects are from autopsies of the
past six years.
II. NATURE AND ORIGIN OF PLAQUES.
The special contributions, as well as incidental notes on mili-
ary plaques, to be found in the literature of the histopathology
2I
of the brain, have been reviewed recently by Perusini' and also by
Huebner’. More recently, and since the completion of the exam-
inations here reported, the paper by Barrett" concerning degenera-
tion of intracellular neurofiibrils associated with miliary gliosis,
the monograph by Simchowicz' on the histopathology of senile
dementia and Alzheimer's" report of a new case of senium praecox
have appeared. In these three last-mentioned papers, plaque
literature is cited in full. The references which follow, therefore,
will not be inclusive, but will be confined to the principal contri-
butions and the views set forth to explain the origin, nature and
clinical significance of the plaques—those peculiar miliary areas
frequently found in the brains of persons dying at an advanced
age and with which psychosis may or may not have been asso-
ciated.
Historical—The observations of Redlich" (1898) with regard
to miliary plaques of the brain concerned two cases of senile
cerebral atrophy—general and focal atrophies—associated clini-
cally with memory defect, mental confusion, amnesic aphasia and
asymbolic apraxia. Similar findings, however, in the brain of
an aged epileptic and the case of an elderly subject who had
shown clinically dementia, aphasia, asymboly and epileptiform
attacks, were reported earlier by Blocq and Marinesco' (1892).
Redlich described the miliary plaques as consisting of numerous
fine glia fibres and moderately large glia cells exhibiting a
slight alteration in shape and some pigmentation, many of the
plaques presenting regressive changes. The regressive changes
were shown in a loss of sharpness in the contour of the prolif-
erated fibres and, occasionally, in a homogeneous or granular
appearance of the entire plaque. These miliary areas, generally
circular in outline and varying in diameter from that of a ganglion
cell to a diameter four to six times as great as such a cell, were
interpreted as the result of focal compensatory glia proliferation
supervening the destruction of ganglion cells. The reason which
Redlich gave for this view was the preponderance of plaques in
cortical laminae where, pari passu, ganglion cells were the most
degenerated. In Redlich’s cases, the layers of small and medium-
size pyramidal cells offered the maximum of ganglion cell de-
generation and plaque formation. It was admitted, however,
that the proliferative changes comprised in each of the miliary
foci were in excess of the reactive gliosis which usually follows
the destruction of a ganglion cell. As to the origin of plaques,
Cramer", in his discussion of the pathological anatomy of the
psychoses (1904), comes to a conclusion similar to Redlich's.
Miliary plaques in the brains of senile dements were also
described by Alzheimer" (1904). In this early observation, the
22
plaques to which Alzheimer called attention were composed of
a felt-work of fine glia fibres surrounding corpora amylacea, or
Other bodies the nature of which was not clear, and were con-
sidered as identical with the miliare Sklerose of Redlich. Later
(1906), at a meeting of the siidwest deutscher Irrenårtge, Alzheimer”
made a preliminary report of a case in which he had found rather
peculiar, and hitherto undescribed, alterations of the intracellular
neurofibrils of cerebral ganglion cells. Associated with the pecu-
liar neurofibril changes were miliary plaques of the cerebral
cortex. In explanation of the plaques, the position was taken
that their presence was due to deposition in the brain tissue of
chemical substances resulting from pathological metabolism of
nervous elements. Various chemical substances, which he desig-
nated collectively as Abbau Produkte, split products of pathological
metabolism could be demonstrated in the plaques by staining sections
with certain dyes after the employment of suitable fixatives.
About the same time (1906), Mijake” reported finding plaques
in the brains of two senile dements. The glial nature of the
plaques was emphasized, for they were described as glia Rosette.
Léri” in his treatise on the senile brain (1906), devotes a
chapter to the particular structures under discussion, there desig-
nated as sclerose nevroglique miliare. Two illustrations are given
of the appearance of the plaques in the cerebral cortex of a
person dying at the age of fifty-eight, having previously suffered
epilepsy, a rather pronounced dementia and marked aphasic dis-
turbances. Léri explained the epileptic attacks in this case as
resulting from the irritation produced by the sclerotic miliary
plaques.
Herxheimer and Gierlich" in their neurofibril studies (1907)
reproduce, photographically, the plaques demonstrated in a section
prepared after the silver impregnation method of Bielschowsky.
These observers look upon the plaques not only as characteristic
of the senile cortex, but also as resulting from greatly altered
cells—swellings and subsequent disintegration.
Fischer” (1907), employing Bielschowsky's neurofibril method
in a series of observations on the cortex of senile dementia and
other psychoses, could find the characteristic plaques in senile
dementia only. Indeed, even in this group of the psychoses,
plaques were confined to cases of presbyophrenia. The patho-
logical process which led to the formation of plaques Fischer
attributed to a “drusy necrosis”; and he was convinced that their
presence in a given brain was of sufficient diagnostic importance
to differentiate presbyophrenia from “simple senile dementia” and
the non-senile psychoses. Later (1908), after having studied
thirty-seven cases of senile dementia, fifty cases of paralytic de-
23
mentia and twenty-three cases of other psychoses, Fischer" was
still unable to find plaques in cases other than presbyophrenia. In
Fischer's earlier communication, club-like proliferations of axis
cylinders surrounding the plaques were described, and these were
assumed to be the result of the necrotic process acting as an
irritant upon the nervous elements. In the later report, the
Opinion as to the nature of the plaques (necrotic foci surrounded
by club-like proliferations of axis cylinders) was modified and
a bacterial origin was argued.
If, as Fischer maintained, the plaques are to be found in cases
of presbyophrenia only (he looks upon them as the anatomical
Substratum of this psychosis) and if their bacterial origin be true,
there would be good warrant for a revision of our conceptions
of presbyophrenia. The psychosis would then come naturally in
the infective-toxic group and would possess a histopathology as
definite as that of general paresis. But the plaques are found in
cases other than presbyophrenia, as this study and the observa-
tions of others show. G. Oppenheim” found plaques in the brain
of an aged man dying from gastric carcinoma but who had
always enjoyed mental health. Perusini' mentions the case of a
young tabetic (thirty-one years of age and without psychosis)
in whose brain Alzheimer found plaques morphologically and
tinctorially identical with the miliary areas encountered in certain
senile brains. In the present series of cases (vide infra) a man
eighty years of age and without psychosis exhibited plaques in
abundance. Moreover, the bacterial origin of the plaques has
not been substantiated by Subsequent observers, nor can the
findings in the group of cases here reported support the claim.
More recently, Fischer" has designated the plaques as
sphaerotrichia multiplex cerebri and contends that in the pictures
furnished by the Bielschowsky method, the fibrillary components
of the plaques are the most characteristic and important, while the
other cellular elements are only secondary and the expression
of a reaction to nerve fibril proliferation.
For Wada,” the plaques are nothing more than circumscript
necroses of the nervous parenchyma and glia apparatus.
Among the more recent investigators who have studied the
plaques, Bonfiglio" (1908) contends that these miliary areas cannot
be explained as the result of focal alterations in axis cylinders,
as Fischer claims, nor as the result of deposition in the brain
tissue of the split products of pathological metabolism, which some
hold to be the case; but the changes which give rise to the
formation of plaques begin with degenerative alterations in gan-
glion cells and the immediately surrounding terminal arboriza-
tions of axis cylinders. Bonfiglio sees in the central nuclear-like
24
mass which characterizes the majority of plaques, nothing but the
necrotic remains of a ganglion cell. This is a view quite in
harmony with the position originally taken by Redlich.
G. Oppenheim" (1909) in six cases of senile dementia with
Symptoms of presbyoprhrenia could demonstrate the plaques in
three of the cases. Two out of three cases of senile dementia with
multiple arteriosclerotic foci exhibited a few plaques, while in the
brain of an aged man (seventy-seven years at death) dying of
gastric carcinoma and without psychosis, plaques were abundant.
Oppenheim also described club-like swellings surrounding the
plaques which, however, were shown by Weigert’s glia stain to
be glia fibers and not axis cylinders.
Perusini' (1909) reports in detail four cases past middle life
which offered clinically much the same mental condition and ana-
tomically presented many plaques, together with most extra-
Ordinary intracellular degeneration of neurofibrils in cerebral
ganglion cells. Preliminary reports had been made on two of
Perusini’s cases, one by Alzheimer” (vide supra) and the other
by Bonfiglio". Perusini's cases were characterized by a slow
but steadily progressive mental enfeeblement, disturbances of
orientation, difficulty in naming objects, intellectual deficit—
amounting in some of the cases to complete mental blindness—
and disturbances of the projection system. Employing Alzheimer's
original description, the peculiar neurofibril changes were thus
reported: “In an otherwise apparently normal cell one or more
fibrils, on account of increased thickness, or intense staining, stand
out prominently. Following this initial change, many of the
neighboring fibrils of the same cell undergo a like change and
are then welded together to form a thicker and more darkly
stained bundle which gradually comes to the surface of the cell.
Finally, the nucleus and interfibrillary protoplasmic substance of
the cell disappear completely and all that remains of the cell is a
darkly stained snarl of neurofibrils.” The plaques were described
as consisting of a central darkly-staining homogeneous mass and
two concentric rings. In the inner ring substances of variable
chemical composition are deposited, the exact character of which
is difficult to determine, while the outer ring is glial in nature.
Although admitting that there is much unknown and many
points not clear as to the clinical significance of these structures,
Perusini offers good reasons for considering the miliary plaques
as resulting from degeneration or disintegration of nervous ele-
ments. Following the destruction of nervous elements, there is a
thickening of the glia reticulum, in the meshes of which the pro-
ducts of pathological metabolism are deposited and undergo
further chemical elaboration. The surrounding glia elements react
25
to the deposit in much the same way as to a foreign body, by an
active fiber proliferation seeking to encapsulate the focus.
Huebner’ (1909) reports two cases over sixty years of age,
not insane, sixteen cases with clinical histories of senile dementia,
senile confusion, senile persecutory delusions, late epilepsy,
multiple focal softenings and aphasia diagnosed on the basis of
anatomical findings. Besides, fourteen cases comprising tubercu-
lous meningitis, purulent meningitis, brain tumor, multiple sclero-
sis, mania, general paresis, dementia praecox, Huntingdon's
chorea and cerebral arteriosclerosis were examined. Huebner
did not find plaques in the two cases without psychosis, but found
them in the case of a manic-depressive seventy-nine years of age
who, however, had shown no considerable dementia during life.
Plaques were also found in the case of an alcoholic dement sixty-
six years of age and in the neighborhood of a recent haemorrhage
into the optic thalamus of an elderly man—a senile dement
sixty-six years of age with clinical symptoms similar to those
of general paresis. In the Special group of fourteen cases, no
plaques were found. Huebner sought to establish whether or not
the presence of plaques in a given series of brains had any
worth as a differential diagnostic factor for presbyophrenia and
also to determine their medico-legal importance. The conclusions
of this observer are as follows: the presence of miliary plaques
in the brain is not characteristic for any special psychosis; that
the subject had at least reached the fifth decade is the most one
could medico-legally advocate.
Bickel” (1910) reports three cases—recent apoplexy in a
subject sixty-five years of age, a focal lesion of five months’
duration as the result of apoplexy in a subject seventy years of
age and the case of a young girl eighteen years of age with
solitary tubercle of the pons—differentiating two varieties of
plaques. One of these varieties is composed of dark and yellow
granules (blood pigments) which have been engulfed by phago-
cytic cells and as the result of grouping or coalescence of such
cells plaques have been formed. The other variety of plaque des-
cribed by Bickel is claimed to be the direct result of ganglion cell
degeneration. It is this latter variety which bears a closer resem-
blance to the plaques discussed in this paper and to which Bickel
assigns an origin identical with that advocated by Redlich.
Barrett" (1911) describes the clinical course and anatomical
findings in eight elderly subjects coming to autopsy in which
plaques were found, seven of the cases presenting the Alzheimer
type of intracellular neurofibril degeneration. Barrett's cases, with
one exception, were “distinctly of the senile period tº ºn
differing from the presbyophrenic form of senile insanity, and
26
pathologically from the arteriosclerotic form.” Symptoms
of Organic brain disease were prominent. Barrett suggests that
the peculiar neurofibril changes in combination with plaques and
certain focal atrophies found in his cases offer “explanations of
a special clinical group of Senile psychoses.”
Simchowicz' (1911) in the report of a study of one hundred
and eight brains from elderly persons, fourteen of which were from
subjects dying without psychosis, thirty-six from subjects with
psychoses which were not of the senile type, the remainder senile
psychoses, lays special stress on the presence of plaques as a
diagnostic anatomical feature of senile dementia. Simchowicz
is of the opinion that those cases which course, clinically, as senile
dementia and yet fail to show plaques, anatomically, probably
belong to a special group, or to other already differentiated psy-
choses. Sixteen cases so considered by Simchowicz are not
convincing; the majority of the cases, judging from the histories
which he cites, could scarcely be considered from their clinical
histories as “senile dementia without a doubt” (to use a not
uncommon phrase) and from the anatomical findings many would
be ruled out instanter. Regarding the plaques, this observer
concludes: With certain exceptions, plaques occur in the brains
of the aged only. Although appearing sparsely in the brains
of elderly subjects without psychoses, plaques may be found with
fair regularly from the eightieth to the ninetieth year onward.
Certain psychic and somatic diseases may hasten the appearance
of plaques. Only in senile dementia are plaques found in great
abundance.
For Simchowicz, the difference between normal senium and
senile dementia is but a difference in degree and he sees in the
plaques to be found in the brains of elderly persons dying with-
out psychosis, together with other interesting histological data
which are ably reported in his paper, further confirmation of
this view.
Alzheimer" (1911) reports an additional case of the type which
he first described and of the same character as the group of cases
reported by Perusini. The case is an example of “Alzheimer's
disease” described in the eighth edition of Kraepelin's Klinische
Psychiatre.* The peculiar type of intracellular neurofibril degen-
eration, however, was not present. The general character of the
plaques, ganglion cell and glia alteration were essentially such
as characterize typical senile dementia. The inference to be
drawn from cases of this character is, that there exists a clinical
state which may be designated as precocious Senile dementia.
Convincing illustrations are given of the histological composition
of the plaques which relieve these structures of much of their
, Vide also papers in this volume on Alzheimer's Disease, by Fuller, and Fuller and Klopp.
27
former mystery. In this case, plaques were found not only in the
cerebrum, but in the cerebellum, medulla and cord as well.
III. MATERIAL EMPLOYED AND ScoPE OF THE PRESENT STUDY.
The brains of thirty-three elderly persons dying with psycho-
ses chiefly of the senile type, small portions of brains from six
elderly persons dying without psychoses and fifty younger sub-
jects dying of a variety of mental diseases furnished the material
for this paper. So far as warranted from the available material,
an attempt has been made to determine the frequency of miliary
plaques in brains of the aged, the clinical significance and the
finer structure of these characteristic bodies. Further, there has
been an effort to establish the fundamental histological differences,
if any such exist, between plaque cases and other cases of the same
general clinical and gross anatomical grouping in which no plaques
were found.
The deductions noted at the end of this paper have been drawn
chiefly from the study of the thirty-three elderly subjects dying in-
sane. Material from elderly subjects without psychosis was limited;
nevertheless, examination of the brain tissue at hand and a re-
view of reported cases were essayed with the purpose of deter-
mining the extent to which the miliary plaques here considered are
an accompaniment of old age—regardless of the existence or non-
existence of a psychosis. The study of material from elderly sub-
jects, however, has been supplemented by a re-examination of
a number of neurofibril slides on file at the pathological labor-
atory of Westborough State Hospital, undertaken with the hope
of obtaining additional data to aid in a satisfactory solution of
the matters in question. The supplementary material—fifty
younger subjects noted above—includes cases of general paresis,
formerly so-called involution melancholia, manic-depressive in-
sanity, dementia praecox, luetic meningo-encephalitis, tuberculous
meningitis, purulent meningitis (streptococcus infection), brain
tumor, chronic alcoholism, microcephalic idiocy, epileptic insanity
and psychosis associated with diffuse degenerations of the spinal
cord (Putnam type) *. Finally, there has been added a consider-
ation of the nature of senile dementia, such as may be deduced
from the general histopathological picture of the brains of persons
dying from this form of mental disease, and a comparison of the
histological lesions of the plaque and non-plaque material from
elderly subjects with reference to their place in the general
histological scheme of senile dementia.
All of the thirty-three cases of elderly persons dying insane,
with three exceptions, fifty-six, fifty-nine, sixty years of age
respectively, were well within the period of senium. From the
clinical data obtainable, and in a certain sense from the anatomical
*Since determined as multiple sclerosis.
28
findings as well, these cases fall readily into three chief groups:
(a) senile dementia, including “simple senile dementia” and
presbyophrenia, (b) arteriosclerotic dementia, with or without
gross focal lesions, and (c) a group in which it is difficult to
appraise clinical symptoms and anatomical findings. In some of
the cases of the last group, there is little doubt as to the presence
of clinical and anatomical signs of senile involution, but whether
or not these have been superimposed on changes which had their
origin' at a much earlier period during the life of the subjects,
the writer is unable to determine.
The incidence of age is shown in the following table:
TABLE I,
Decade. No. of
C3 SeS
6th . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
7th . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II
8th . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IO
9th . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Total cases 33
º
IV. ANALYSIS OF GRoss ANATOMICAL FINDINGs witH
REFERENCE TO PLAQUES.
The material was first arranged in two groups, (a) atrophic
brains, (b) normal-weight brains, and studied with reference to
the frequency with which atrophy and plaques were associated
and the possible etiological relationship of brain wasting to the
formaton of plaques. The miliary plaques with which we are
concerned were first reported in connection with cases of senile
cerebral atrophy (vide supra Redlich, Blocq and Marinesco); it
seemed well, therefore, to establish for this series the extent to
which the presence of plaques was dependent upon, or only coin-
cident with brain wasting.
Atrophic Brains.—Twenty-six cases in the series, fifteen men
and eleven women, presented atrophic brains. Eleven of the
atrophic brains, six from males and five from females, exhibited
plaques. But the two most atrophic brains in the entire series,
82I.I and 900. I grams respectively, both from women, failed to
show the characteristic miliary structures.
Normal-weight Brains.—Assuming I358 grams as the normal
average brain weight for men and I235 grams as the normal
average weight for women, seven subjects furnished brains well
within the range of normal weights. It is well to note, however,
that of the seven normal-weight brains four exhibited focal atro-
phies, two of these in addition presenting multiple focal softenings
and lacunae. The remaining three cases of the group were without
29
macroscopic evidence of atrophy. Five of the seven normal-
weight brains, four men and one woman, yielded plaques in
abundance. Of the four normal-weight brains with focal atrophies,
three contained plaques. y
While the conditions which make for atrophy may also be
directly or indirectly responsible for plaques, it is obvious from this
analysis that plaques cannot be postulated from atrophy alone.
Forty-two and three-tenths per cent of the atrophic brains in the
series and fifty-seven per cent of the normal-weight brains ex-
hibited plaques. A predisposition in favor of riormal-weight brains,
however, must not be assumed, for the reason that the cases are
too few from which to draw such conclusions; furthermore, as
will be shown later, plaques are probably dependent upon quite
different factors.
A second grouping of the material was effected with the
view of ascertaining the possible influence of coarse brain lesions
in the production of plaques, lesions such as haemorrhages into
the brain substance and meninges, gross focal Softenings, lacunae,
etc., resulting from arteriosclerotic cerebral vessels.
It has been shown that more than half of the brains which
were well within the range of normal-weight presented focal
lesions—atrophies, softenings and other evidence of cerebral
arteriosclerosis. It has also been shown that atrophic as well as
normal-weight brains may exhibit plaques. On the other hand,
many brains in which, judging from gross anatomical findings and
the clinical course as well, one might reasonably expect to find
plaques, proved disappointing, while frequently some of the least
suspected subjects were the most fruitful in their yield of the
characteristic structures. Thus an attempt to establish, as it
were, a type of brain at the autopsy table which would show
plaques on microscopical examination has been most baffling.
The following groups while not wholly satisfactory give some idea
of the general gross condition of the brains in this series of cases
in which plaques were found on microscopical examination:
(1) Atrophy, Arteriosclerosis Without Focal Lesions.—Ten
brains constitute this group, five exhibiting plaques. Thus 31.2
per cent. of all plaques cases were found in group I.
(2) Atrophy, Arteriosclerosis, Focal Lesions.—Fifteen brains
are included in this group, in six of which plaques were found.
This group, then, furnished 37.5 per cent of the plaque cases.
(3) Normal-weight Without Focal Lesions, Arteriosclerosis.-Of
the two brains so grouped, I or 6.25 per cent of the series showed
plaques in abundance.
(4) Normal-weight, Focal Lesions, Arteriosclerosis.--This
group contained five brains, four showing plaques. The percent-
age of all plaque cases coming from this group was 25.
3O
(5) Atrophy Without Arteriosclerosis.-One brain was so
classed, which however, is open to question. An entire absence of
arteriosclerosis can not be maintained, for the basilar artery exhi-
bited macroscopically a few atheromatous patches (possibly
Syphilitic arteritis of the Heubne rtype). The case offered clini-
cally many features common to psychosis of the involution period,
and yet the histological lesions must be classed as a combination
of chronic meningo-encephalitis with cerebral syphilis of the
endothelial type (Alzheimer"), or the combined inflammatory and
non-inflammatory form of cerebral lues (Nissl).” No plaques
found.
Summarizing the results of the gross anatomical grouping of
the material we find: (a) out of a total of thirty-three brains from
elderly persons dying insane sixteen or 48.48 per cent. furnished
plaques. (b) Ten or 62.5 per cent of the plaque brains exhibited
gross focal lesions. (c) Fourteen or 87.5 per cent of plaque
brains displayed macroscopically atrophy which was either diffuse
Or focal in character. Instances of the combination of the two
forms of atrophy were common.
Clinical abstracts and anatomical diagnoses of the cases pre-
senting plaques are given in the succeeding section.
V. THE PLAQUE CASEs AMONG ELDERLY SUBJECTs DYING
INSANE.
l Clinical Abstracts of Plaque Cases.
CASE I.—W. S. H., No. 8723, a retired farmer, eighty-four years of age,
with a negative family history for nervous and mental diseases, enjoyed
general good health until the middle of his eighty-second year. About that
time, mental and pronounced physical failure began to be apparent and for the
eighteen months prior to admission was steadily progressive. Financial losses
seem to have played a role in the mental breakdown. Loss of weight, general
asthenia, insomnia and memory defect were among the first troublesome
symptoms. Memory became impaired, so that, even the grossest events, remote
and recent, were recalled with difficulty or forgotten entirely. He could not
recall the names of old associates and frequently forgot the names of those in
his immediate family. The gaps in memory were often filled in with fabrica-
tions. In the two months preceding admission to hospital, periods of con-
fusion had been noted, he roamed about the house in an aimless manner and
on one occasion attempted to move the lighted cook stove from one room to
another. Other equally senseless and dangerous acts were attempted in
the confused periods. He frequently talked aloud to himself and at such
times the speech content was paraphasic or jargonic. He gave evidence of
auditory hallucinations. There was loss of bladder and rectal control which
made it more difficult to care for him at home.
On admission to Westborough State Hospital, a markedly emaciated
and feeble old man barely able to walk, whose gait was that of senile trep-
idant abasia, presented. The heart sounds were feeble and irregular, no mur-
murs detected. Respirations I6 per minute, råles of all kinds heard over the
chest. The skin was very dry and ashy in appearance, presenting recent
bruises over shoulder and Scalp.
Rnee jerks absent (resistance?); elbow, wrist, pectoral and abdominal
reflexes elicited; cremasteric absent. Left sided Babinsky; no Oppenheim;
3I
no evidence of cranial nerve palsies or other paralyses. Examination for
sensory disturbances unsatisfactory, patient did not coöperate, but pain sense
intact.
Mentally the patient took no notice of his surroundings. Although he
attempted replies to questions, his answers were irrelevent, incoherent and at
times paraphasic. The emissive quality of speech was thick, low-pitched and
attended with considerable motor difficulty. There was apparent mental
confusion and quite a little psycho-motor unrest, all of which made the ex-
amination quite unsatisfactory.
The day following admission, the symptoms of a cerebral haemorrhage
suddenly developed: loss of consciousness, clonic spasms of the right side of
face and right arm, followed by a right hemiplegia. Consciousness was not
regained. A sub-normal temperature (94°F. rectal) was carried constantly
until his death four days later.
Anatomical Diagnosis.-Increased density of calvarium, dural herniaº (in-
vaginations of pia and Pacchionian granulations), pachymeningitis haem-
orrhagica interna, chronic leptomeningitis, atrophy of cerebral gyri, advanced
cerebral arteriosclerosis, granular ependymitis; cardiac displacement (heart
placed at right angle to long axis of body), abnormally long ascending aorta
(9 cm.), chronic endocarditis; chronic pleuritis; congestion and interstitial
hepatitis; chronic perisplenitis and interstitial splenitis, chronic interstitial
pancreatitis; gastritis; chronic interstitial nephritis; cystitis, enlarged pros-
tate.
CASE II.-W. S. H., No. 6753, a man seventy years of age suffered an
attack of influenza two years ago, up to which time he had always enjoyed
good health. Syphilitic infection was denied. He had never used alcohol, had
been successful in life as a jeweler and was considered above the average
mentally. Following the attack of influenza he never regained his former
strength; practically all this period he grew weaker, slept poorly and lost in
weight. Impairment of memory was progressive. He was finally able to
recall only the grossest events of the remote past. He had a tendency to
wander away from home and could not find his way in previously familiar
localities. There were periods of considerable motor restlessness, appre-
hension and excitement, during which he gave expression to delusions of ill-
treatment on the part of his family. During periods of excitement he
jumped from a window, assaulted his wife and daughter with a chair, tore
bed clothing and was otherwise destructive. The patient’s father died of
apoplexy; no other family history of importance elicited.
On admission, a poorly nourished old man presented a general appear-
ance of feebleness. There was a systolic murmur; respirations shallow,
slight dullness over both apices. The skin was dry; arcus senilis; peripheral
arteriosclerosis and general tremor were present.
Neurological Examination.—Knee-jerks slightly increased; abdominal,
cremasteric, elbow and wrist reflexes elicited. Slight swaying to Romberg;
no paralyses of cranial nerves or other paralyses; no cutaneous sensory
disturbances detected. Pupils react sluggishly to light and accommodation.
Mentally the patient was without grasp on his surroundings; he was dis-
oriented for time and place, and showed a marked impairment of memory.
He talked freely but was rather prolix; and thought his relatives had sent
him to prison. He cried easily without any apparent adequate cause and ex-
hibited a mild depression. No evidence of aphasic disturbances; no halluci-
nations determined.
The day following admission there was considerable motor restlessness
and crying, a condition which persisted for three weeks, when he developed
a temperature of Io:3 F. (rectal). Restlessness increased and visual and
auditory hallucinations developed. He became unconscious during the first
day of the increased temperature and remained so for five days. Death.
|Anatomical Diagnosis-Chronic external pachymeningitis, atrophy of
pia, hydrocephalus ex vacuo, focal atrophy of cerebral gyri, advanced cere-
bral arteriosclerosis, multiple focal softenings and lacunae in corona radiata
and basal ganglia; chronic interstitial hepatitis; chronic interstitial splen-
itis; chronic interstitial nephritis; acute enteritis.
32
. CASE III.--W. S. H., No. 8600, a man seventy-two years of age, concern-
ing whom his immediate relatives could give no information as to his previous
history since youth, except to state that for many years he had complained, in
letters sent home, of kidney disease and rupture. The patient was of a
roving disposition, going from one place to another all over the country,
remaining nowhere any length of time. Two paternal cousins are patients
at this hospital.
. In the latter part of July, 1909, the patient suffered an attack of ptomaine
poisoning during which he was delirious. He was seemingly making a good
recovery when on August 4th, about ten days after the onset of the toxic dis-
turbance, he suddenly got out of bed, left his room and attempted to force
an entrance into other rooms of the house where he was lodging. Unsuc-
cessful in these attempts he finally jumped from a window and made his way
to the street, where he created a scene while being returned to his lodging.
Immediately following this episode the patient was committed to the Boston
State Hospital as an emergency case. On arrival at the hospital he was re-
ported as being in a weak and exhausted condition. For four days he was
kept in bed and during this period was quite irritable and fault-finding, and
made many unreasonable demands. There does not appear to have been any
clouding of consciousness. Six days after admission to Boston State Hospital
his physical condition improved sufficiently to warrant his being up and
dressed. Following this he was less fault-finding and on the whole quite
cheerful. Transferred to Westborough State Hospital September 22, 1909.
On admission, a poorly nourished old man who looked his age. Moderate
use of alcohol was admitted, previous venereal disease denied. The heart's ac-
tion was weak and irregular and there was increased cardiac dullness; no
murmurs detected. Pulmonary sounds not pathological; no lesions of other
viscera noted. The skin was flabby, parchment-like, and, except for head and
eyebrows, entirely devoid of hair. Well defined arcus senilis and marked
peripheral arteriosclerosis presented.
|Knee, wrist, elbow, pectoral, abdominal, cremasteric and plantar re-
flexes elicited. No Babinsky; no Oppenheim phenomena. Coördination
tests fairly well executed, although there was a general tremor of the Senile
type. The tongue deviated to the right when protruded and there was slight
swaying to Romberg. Pupils reacted promptly to light and accommodation.
No sensory cutaneous disturbances detected.
Mentally the patient was mildly exhilarated ; he expressed ideas of self-
importance and frequently assumed dramatic attitudes. He also gave ex-
pression to delusions of persecution, repeating frequently, “Wealth keeps
me here.” He insisted that he was drugged by the physician who attended
him before he was sent to Boston State Hospital and in order to avoid a suit
which he intended to bring against the doctor, the latter had him committed
as an insane person. He was oriented for the time and place. Memory was
defective especially for recent events. He was rather garrulous and prolix.
The above was much his condition throughout, memory defect increased
all the while. April 6, 1910, seven months after admission, he complained of
considerable pain in the cardiac region which grew worse until death, nine
days later.
Anatomical Diagnosis-Pachymeningitis haemorrhagica interna, chronic
leptomeningitis, cerebral arteriosclerosis; cardiac dilatation; emphysema; in-
terstitial hepatitis; gastritis, enteritis; chronic interstitial nephritis.
CASE IV.-W. S. H., No. 8939, a man sixty-six years of age without
previous mental disease or any other serious illness, enjoyed good health until
the age of sixty-four. A moderate use of alcohol was admitted, syphilis
denied. During a hot day two summers ago the patient went fishing. The
greater part of the day was spent on the river fishing, from a small boat.
in the late afternoon, after reaching the shore and while preparing to start
for home, he suddenly became very weak in the legs so that he could not
walk without assistance and had to be practically carried by two men. . At
the same time his speech became affected—for the most part unintelligible—
and with equal suddenness his vision was so impaired that it was very doubt-
ful whether he could see at all. This attack was diagnosed a “sun-stroke,”
33
for which he was accordingly treated. His son, who was with him at the time
and furnished the information, states that, dating from this episode he rapidly
failed physically, but the mental failure was gradual and only during the
last two months had it been pronounced. Memory, which became impaired
soon after his illness, was so deficient that at times he was unable to recall
the names of his immediate relatives. There were periods of confusion in
which he would wander about aimlessly. His gait became so impaired that he
could not go without stumbling a great deal and falling frequently. When
down, the patient was too weak to rise without assistance. He was actively
hallucinated (auditory), noisy and restless at night. For three weeks prior
to admission there was loss of bladder and rectal control.
On admission, a fairly well nourished old man presented, who looked,
however, considerably older than his reported age. When assisted he was
able to walk, but unaided stumbled and fell easily. The gait was spastic.
The senseless resistance which the patient offered to everything rendered the
examination unsatisfactory, but an enlargement of the cardiac area was
detected and the heart’s action was weak and irregular. No pathological
pulmonary sounds were noted, or gross lesion of the abdominal viscera.
There were varicose veins of the lower extremities, marked arcus senilis
and peripheral arteriosclerosis; all tendon reflexes active. The pupils were
unequal and reacted sluggishly to light; accommodation test unsatisfactory.
There was a nystagmus of the left eyeball. A general tremor was present and
considerable motor unrest.
Mentally the patient was disoriented, for the most part confused. Dur-
ing the short intervals when he seemed fairly clear, he mistook the hospital
personnel for old acquaintances. The speech was drawling and frequently
unintelligible—a mere jargon. Many of the questions addressed to him were
apparently not comprehended, for instead of replying he often looked about
in a bewildered manner. Stool and urine were passed involuntarily. This was
his condition throughout. A week after admission a lobar pneumonia de-
veloped from which the patient died.
Anatomical Diagnosis.-Chronic external pachymeningitis, chronic lepto-
meningitis, cerebral atrophy, advanced cerebral arteriosclerosis, no gross
focal lesions of brain; marked cardiac hypertrophy (cors bovis), chronic en-
dorcarditis, chronic interstitial myocarditis, atheromatous degeneration of
aorta, coronary and peripheral arteriosclerosis; pleuritis, pulmonary conges-
tion and Oedema; hepatic congestion; moderate splenomegally, interstitial
proliferation; interstitial pancreatitis; moderate interstitial nephritis.
CASE V.—W. S. H., No. 8453, a woman seventy-nine years of age, had suf-
fered several attacks of serious illness during her life: typhoid fever at the
age of sixteen, from her thirtieth to her fortieth year chronic gastritis which
gave much trouble, a second attack of typhoid with “brain fever” at fifty and
when fifty-one an attack of insanity which lasted for 18 months. Following
the attack of insanity there was recovery with defect, for she was never
quite the same as before—absentminded, disinclined to meet strangers,
feared going out alone, easily excited and given to talking to herself. Never-
theless, it was possible to care for her at home without any inconvenience to
the peace of the family. At the age of seventy-four memory defect began to
be apparent and as this increased, the gaps in memory were quite regularly
filled in with fabrications. Periods of confusion were frequent. Contrary to
her life-long disposition she became very irritable, and developed the idea that
she was being persecuted and otherwise ill-treated by her relatives. With ad-
vancing mental deterioration she frequently threatened violence, was noisy
and restless at night, talked obscenely, complained of numerous parasthesias,
lost control of rectal and bladder functions, gave evidence of auditory, visual
and tactile hallucinations and finally failed to recognize the members of her
household. No history of alcoholism or of venereal disease. Family history
negative.
On admission an extremely anaemic, emaciated, feeble, old woman
who was unable to walk. She presented a general senile tremor and a tum-
efaction of the left parotid gland. The heart's action was labored and inter-
mittent and there was a harsh friction sound at the apex. General peripheral
34
arteriosclerosis. Blood examination revealed Hb. I4, red cells 1,600,000.
Respiratory sounds were harsh, no rāles. Examination of urine showed the
presence of hyaline and fine granular casts. Paralysis of bladder (necessary
to catheterize) and rectal incontinence existed. Quite a little negativism was
exhibited.
Both knee jerks were increased and a questionable double Babinsky
elicited; other reflexes unsatisfactory. Left cornea opaque; right pupil re-
acted sluggishly to light; patient did not coöperate for accommodation test;
cutaneous pain sense intact. Patient complained of numerous paraethesias of
trunk and extremities (lower). Hearing in right ear good, in left greatly
impaired.
Mentally the patient exhibited alternating periods of confusion with
periods of a fair degree of clearness. She was completely disoriented and
without insight. After two hours in the hospital she could not tell how
long here or where she came from. She gave expression to delusions of
persecution, believing she was drugged an I annoyed constantly by enemies.
Memory impairment for both remote and recent events was marked.
After a month in hospital, during which there were periods of stupor
and somnolency alternating with periods of excitement, the patient seemed a
little better mentally than when admitted. After two months in hospital, a
diarrhoea developed which so weakened her that death followed in a few
days after its onset.
Anatomical Diagnosis.-Chronic external pachymeningitis, chronic
leptomeningitis, hydrocephalus, ex vacuo, atrophy of cerebral gyri, ad-
vanced cerebral arteriosclerosis, multiple cerebral lacunae and softenings;
chronic endocarditis, chronic aortitis, advanced atheromatosis of aorta,
ilac vessels and peripheral arteries, interstitial myocarditis; hypostatic
pneumonia, chronic pleuritis; eneritis; chronic interstitial hepatitis; 'chronic
interstitial nephritis.
CASE VI.-W. S. H., No. 8892, a man eighty-three years of age sustained
a Pott's fracture in a street railway accident twelve years ago, up to which
time he had suffered no serious illness or previous injury of any moment.
Since this street car accident he has steadily failed, physically as well as men-
tally. Ten years ago he passed through an attack of Scarlet fever which left
him deaf in the left ear. It was noted that his memory was poor soon after
the accident and the impairment later became extreme. During the past four
years he was a great care to his family, showing a tendency to wander away
from home in an aimless and confused manner. For two years he had fre-
quent short periods of excitement, at which times he threatened violence and
on one occasion very nearly killed his aged wife by choking her. He was
hard of hearing for some years and the deafness 1ncreased perceptibly.
There were periods when he was extremely noisy, other times when he was
given to weeping a good deal, and occasions which his friends described as
“stupid” were frequent. He was untidy and extremely garrulous, although
the speech was at times very indistinct and unintelligible on account of motor
difficulty with resulting defective pronunciation, and also on account of its
araphasic or jargonic character.
p É. 㺠an obese, somewhat jaundiged and feeble old man pre-
sented who looked his age, and who was unable to stand alone, but when
supported could walk, although in a halting and extremely trepidant manner.
There was an enlargement of the area of cardiac dullness, and a systolic
murmur heard over the whole of the praecordia, though best at the apex.
Vesicular breathing and råles were heard over both lungs. Varicose veins of
the lower extremities and peripheral arteriosclerosis were present. Arcus
senilis. Sight was defective in both eyes (presbyopia), impairment of hear-
ing in right ear and total deafness, in left. Deep and superficial reflexes
elicited; pupils reacted to light and accommodation. There was a loss of
bladder and rectal control. & d º º
Mental examination was difficult on account of the impairment in hearing,
but it was ascertained that memory was defective, especially for recent events.
Insight was superficial. There was a degree of depression and some appre-
hension when talking of home and family, but otherwise a mild euphoria
existed.
35
The patient was in hospital for a period of five and a half months, during
all of which time he grew worse. There were periods of irascibility, mental
confusion and occasionally fabrications to fill in memory gaps. Finally there
was loss of cardiac compensation resulting in death.
Anatomical Diagnosis.-Increased density of calvarium, chronic hyper-
trophic leptomeningitis, internal and external hydrocephalus, advanced cere-
bral arteriosclerosis, atrophy of cerebral gyri; chronic endocarditis, chronic
interstitial myocarditis; pleuritis, emphysema; chronic interstitial hepatitis;
chronic interstitial splenitis; chronic interstitial nephritis; cystitis.
CASE VII,_W. S. H., No. 8652, was a man eighty-nine years of age.
Very meagre family and personal history was obtained from the overseer of
the poor. Father of patient was reported to have been a hard drinker, he
himself a moderate user of alcoholic stimulants. About a year prior to ad-
mission to hospital, delusions were evidenced to those who knew him. About
this time it was noted that his memory was very defective for remote as well
as recent events, and that he frequently fabricated experiences. During the
year he had grown steadily worse. He was often noisy and restless at night,
extremely profane and obscene in his language, irritable, stubborn (nega-
tivism); he feared that his belongings would be stolen, made indecent pro-
posals to women and exposed his person in public.
On admission, a markedly emaciated old man, unkempt in appearance,
presented a skin eruption due to scabies, a general senile tremor and sen-
nile trepidant abasia. Heart sounds accentuated, rapid, irregular; no murmurs
detected; area of cardiac dullness normal. Respiratory sounds were not
pathological. No disturbances of reflexes that were of significance; sight
and hearing in fair preservation.
Mentally, comprehension was good as evidenced in the speech reactions:
disorientation for time and place. Memory was defective’ for recent events.
The patient was irritated by the questions of examiner. He defecated and
urinated in bed.
During hospital residence there was no improvement in his condition.
He was noisy and irritable when not asleep. The patient, however, slept
a great deal. Untidiness persisted. A dysentery developed soon after ad-
mission and persisted to the end, the patient dying on the twelfth day after
admission.
Anatomical Liagnosis.-External pachymeningitis chronica, leptomen-
ingitis chronica, cerebral atrophy, advanced cerebral arteriosclerosis; chronic
endocarditis; pleuritis, septic pneumonitis; chronic interstitial hepatitis;
chronic interstitial splenitis; gastritis; chronic interstitial nephritis.
CASE VIII.-W. S. H., No. 8627, a man sixty years of age had suffered
no serious illness until the present mental attack which the family believed
had its onset five years ago. At that time the announcement by telegram
of the sudden death of a son from whom he expected a visit affected him
greatly. After this event he seemed to lose interest in things in general,
was hard to please and kept to himself—conduct quite contrary to his former
genial disposition and social habits. It was noticed too, that, dating from his
son's death, his speech utterances were slightly defective—often indistinct,
difficulty in pronouncing many common words and in finding the proper
word to employ. He also complained of numbness in the right arm, but
was able to continue at work as a machinist. Three months before admis-
sion to hospital he suffered a second “slight shock” which, however, did
not incapacitate him for work. Finally, four days before admission, he
returned home rather late from work complaining that he could not see.
Soon after arriving home he became unconscious, associated with which
there was considerable restlessness and moaning as though in pain. The
day following, consciousness was regained. At this time the patient had
partial insight into his condition, but exhibited a degree of apprehension
which perhaps was not excessive considering the gravity of his case. Dur-
ing the three days before admission he was quite restless and depressed,
finally refusing food for fear of being poisoned. The father of the patient
died from apoplexy.
On admission, a fairly well developed man, but he was extremely
36
nervous and haggard in appearance. He looked considerably older than
his reported age, and walked with a spastic gait. Other than increased
action and accentuation of the first sound, the heart offered nothing of .
Special interest. There was, however, general peripheral arteriosclerosis.
Lungs, negative; kidneys, chronic interstitial nephritis (urinalysis). Other
abdominal viscera negative.
The protruded tongue deviated to the left. The pupils reacted sluggishly
to light and accommodation. Elbow, wrist, pectoral and abdominal reflexes
active. Knee jerks increased, especially the right, and there was a right
sided Babinsky. Poor coördination of upper extremities, gait spastic, sta-
tion unsteady. tº &
Good orientation for place and persons, poor for time. Emotionally,
the patient was unstable, crying a great deal without adequate cause. On
the whole, mental processes were slow. Questions were comprehended
slowly and there was a motor difficulty in getting out his words.
Following admission the patient improved rapidly and in less than a
month was permitted to leave the hospital. For a few weeks after leaving
hospital he continued to do well, then he again grew irritable and fault-
finding, showed a decided memory defect and failed physically. Four months
after leaving hospital he was readmitted with all symptoms noted at first
admission intensified. Nevertheless, there was considerable insight ex-
hibited by patient and he admitted periods of confusion. Two weeks after
his return to hospital a cerebral insult occurred. Consciousness was not
recovered, death four days later.
Anatomical Diagnosis-Pachymeningitis haemorrhagica interna, chronic
hypertrophic leptomeningitis, advanced cerebral arteriosclerosis, recent
haemorrhage into the right optic thalamus, soft brain; cardiac hypertrophy;
pulmonary hypostasis; hepatic congestion; chronic interstitial nephritis, cystic
degeneration of kidneys.
CASE IX—W. S. H., No. 8633, a woman eighty-one years of age showed
mental symptoms at the age of seventy-eight. She had had most of the
children's diseases, including Scarlatina at the age of two; menopause at
fifty without special mental symptoms. Mother of patient was insane (senile
dementia). At seventy-eight memory defect was noted and later romancing
was common. About this time she charged her husband, an old man, with
dissolute living, and developed the idea that neighbors were “down on her.”
These delusions increased rather than diminished, in consequence of which
she frequently threatened violence. Auditory and visual hallucinations be-
came so prominent that it was necessary to commit her.
On admission, an old woman, well developed and well preserved
physically, presented. She was, however, extremely resistive and would not
submit to a physical examination, giving as a reason that she had been
illegally sent to hospital and that there was nothing the matter with her.
There was evidence of peripheral arteriosclerosis. She admitted “voices”
and charged enemies as being responsible for her presence here. She was
very bitter against her husband. Comprehension good; orientation defec-
tive. School knowledge deficient and memory greatly impaired, especially
for recent events.
The patient remained in hospital a year and three months, during
which period she was for the most part, sullen and irascible. She con-
tinued to show marked disturbances of memory and was frequently halluci-
nated. A week before she met death with an accident—a fall resulting in
an intracapsular fracture of the femur. The day before death, cerebral in-
sult, followed by death within twenty-four hours.
Anatomical Diagnosis.-External pachymeningitis, pachymeningitis
haemorrhagica interna, general cerebral congestion, atrophy of cerebral gyri,
advanced cerebral arteriosclerosis, no other gross focal lesions of brain;
chronic endocarditis, general peripheral arteriosclerosis; pulmonary conges-
tion and oedema; fatty liver; chronic interstitial nephritis; intra capsular
fracture of head of femur.
CASE X.—W. S. H., No. 4865, a man, seventy-one years of age, who
previous to his mental breakdown had never suffered serious illness, began
37
to show mental symptoms at the age of sixty-six. These were at first mild--
an unaccustomed garrulity, and memory defect which gradually increased.
Later, auditory hallucinations appeared, and he developed the idea that his
relatives wished to poison him. Added to these there was loss of bladder
and rectal control.
On admission, a fairly well nourished old man presented a general senile
tremor, the gait halting and extremely trepidant. The heart's action was
rather rapid and feeble. There was general peripheral arteriosclerosis. Lung
examination revealed nothing of significance. A urinalysis showed the ex-
istence of a chronic interstitial nephritis. The pupils reacted normally to
light and accommodation and were circular and equal; tendon reflexes
sluggish; cutaneous pain sensations diminished.
Mentally the patient was dull and apparently indifferent to his sur-
roundings. He comprehended slowly. Memory was defective for recent
events, good for remote happenings. He expressed delusione of poisoning,
as noted above.
Following admission there was gradual improvement for a period of
seven months, when the patient suffered a cerebral insult. Although the
shock did not prove fatal and was without motor residuals (limb paralyses)
the dementia which ensued was pronounced. Six months before death a
second insult, followed by aphasic symptoms of a sensory type which, while
not disappearing wholly, greatly improved. Three months before death a
third insult with motor and sensory residuals. Death supervened three months
later, suddenly, after a hospital residence of four years.
Anatomical Diagnosis.-Chronic leptomeningitis, advanced cerebral
arteriosclerosis, cerebral atrophy, post apoplectic softenings and cyst-like
lacunae in cortex and basal ganglia; destruction of Tº supervened, left, head
of caudate nucleus and greater portion of putamen on left side, heterotropia
of lumbar and thoracic cord; cardiac hypertrophy chronic endocarditis,
chronic interstitial myocarditis; chronic interstitial nephritis.
CASE XI.-W. S. H., No. 9252, a woman seventy-seven years of age, of
whom it is said she had enjoyed good health up to two years ago. Her hus-
band had died some years previously and she had been forced to work hard
for support. Meanwhile, her remaining relatives, four sisters to whom she
had been devoted, also died, which was the source of much grief, and she
never seemed to quite reconcile herself to their death. At the age of seventy-
five she was growing feeble physically and friends began to note that her
memory was defective. Her chief interest seemed to be in the remote past,
for she talked chiefly of associates long since dead. For several years she
had been hard of hearing. As the memory defect progressed she frequently
failed to recognize familiar faces. During the year prior to admission she
was often restless and confused. She also showed a tendency to stray away
and developed the idea that she possessed a sum of money in a certain
bank—an institution with which formerly she carried an account. During
this period, speech disorder of a sensory type developed, her restlessness
increased and she became so noisy that it was no longer possible to care
for her at the home for the aged, where she had been an inmate for about
two years.
On admission, a fairly well nourished, but rather feeble old woman pre-
sented, who was also extremely restless and talkative, besides exhibiting a
general tremor. Heart, lungs and other viscera offered no special patho-
logical condition. Pupillary reaction sluggish; tendon reflexes normal.
Mentally, the patient seemed quite confused. Although talkative, the
speech content was irrelevant. When addressed she did not answer ques-
tions, and it was difficult to determine whether the failure to react was due
to deafness, inattention or to a sensory aphasia. A few days later she
named several objects correctly. Usually, however, the speech content was
absolutely irrelevant.
She suffered two attacks of catarrhal jaundice of a mild degree at an
interval of a month between recovery from first and advent of second
attack. Two months after admission, death from lobar pneumonia.
Anatomical Diagnosis.-Chronic external pachymeningitis, chronic
38
leptomeningitis, general cerebral atrophy, cerebral asymmetry due to pro-
nounced atrophy of left temperosphenoidal lobe, dilatation of post-horn of
lateral ventricle; chronic endocarditis, calcareous degen. of coronaries,
peripheral arteriosclerosis; pleuritis, lobar pneumonia; hepatic congestion;
chronic perisplenitis, splenic congestion; gastritis; chronic interstitial
nephritis.
CASE XII.-W. S. H., No. 9364, a woman seventy-nine years of age,
mother of sixteen children, eleven of whom are living and well, had enjoyed
good health, except for an attack of rheumatic fever at the age of forty,
until five years ago when she met with an accident—she fell striking the
head. As a result she was unconscious for some time (length of time not
Stated) and was later delirious. From the immediate effects of the injury
She apparently recovered, but soon afterwards her memory failed perceptibly
and grew steadily worse. She could not recall the names of life-long friends
but apparently remembered their faces. She began to sleep poorly, was
usually restless and roamed about the house at night in an aimless manner.
She talked a great deal, but the speech content was rambling and often in-
ct herent. Contrary to her former mood she was very irascible, she re-
peatedly threw objects at members of the family and on one occasion seized
a knife with the intent to assault.
On admission, a fairly well nourished old woman, quite restless, talk-
ative and negativistic, presented a right facial paralysis and arthritis de-
formans of both hands. On account of the extreme restlessness and sense-
less resistance, a physical examination was unsatisfactory, but a mitral mur-
mur, increased and irregular heart's action were detected. Respiratory sounds
not pathological; arcus senilis and peripheral arteriosclerosis. Pupils re-
acted to light and accommodation. Hearing was greatly impaired. Right
knee jerk increased on right side. No Babinsky elicited.
Mentally, the patient appeared confused. Although she replied to ques-
tions, the speech content was seldom relevant. Despite the resistance, she
was rather good-natured, laughing at the happenings about her. Later, the
patient was restless and noisy and roamed about the ward, frequently dis-
turbing other patients.
Ten days after admission very somnolent; inequality of pupils; twitch-
ings of extremities of the left side; attacks of choking. Three weeks after
admission, she died.
Anatomical Diagnosis.-Increased density of calvarium, congestion and
increased tension of dura, chronic leptomeningitis, external hydrocephalus,
cerebral atrophy, advanced cerebral arteriosclerosis, comparatively recent
haemorrhages in left putamen, antr. limb of right internal capsule and in
antr. portion of corona radiata on right side; cardiac hypertrophy; chronic
adhesive pleuritis, pulmonary hypostasis; fatty liver; diffuse nephritis.
CASE XIII.-W. S. H., No. 8032, a woman eighty-seven years of age,
had, until a year or more prior to admission, enjoyed good health, and was
a self-reliant and ambitious person. Nevertheless, she was more or less
difficult to “get on with.” because of her inflexible opinions. Relatives, there-
fore, had kept little in touch with her, so there is no good account of the
exact onset of the mental state. For more than a year she had been in
poor health, and this together with financial losses and the recent death of
an only daughter who had lived with her seemed to have been potent factors
as exciting cause for the outbreak of the psychosis. She became extremely
garrulous and forgetful and showed a slight tendency to romance. She
claimed to be without food in the house when there were ample provisions,
and she felt that she was being ill treated by a certain man who, on the
contrary, was showing nothing but the greatest interest in her welfare.
On admission, a poorly nourished and feeble old woman exhibited an
advanced state of peripheral arteriosclerosis. The heart's action was rapid
and accentuated and there was a systolic murmur. Respiratory sounds were
rather harsh. A urinalysis revealed a few hyaline casts and a small amount
of sugar. Gait rather tottering; station unsteady. She did not coöperate
in the neurological examination for the reason, as she stated, that she
should not have been sent here. Hearing was greatly impaired; it was
necessary to shout at the patient in order to be heard. Arcus senilis.
39
Mentally, the patient comprehended, when she could be made to hear,
She was very noisy and was indignant to find herself in a hospital for the
insane. She said she was deceived by those who brought her here. She was
very prolix. No hallucinations.
The day following, she was quite exhilarated and attempted to give her
fellow patients an exhibition of fancy dancing. Following the excitement
she grew more reconciled to her stay. She remained in hospital two years
and a half, exhibiting frequent alternations of periods of comparative com-
fort and cheerfulness and periods of slight depression and hypochondriasis
ºther with pains in the gastric region. Death from perforating gastric
111Cer.
Anatomical Diagnosis.-External pachymeningitis chronica, chronic
leptomeningitis, advanced cerebral arteriosclerosis, atrophy of cerebral gyri;
cardiac hypertrophy, aortic stenosis, chronic interstitial myocarditis;
pleuritis, pulmonary congestion; acute perihepatitis, chronic interstitial
hepatitis; acute perisplenitis, chronic interstitial splenitis; gastritis, per-
forating gastric ulcer, acute fulminating peritonitis; chronic interstitial
nephritis; general peripheral arteriosclerosis.
CASE XIV.-W. S. H., No. 7IO3, a woman eighty-four years of age, con-
cerning whose previous history little is known except that for four or five
years prior to admission she had been failing mentally. During the year
before coming to hospital her memory was so defective that she did not
recognize old acquaintances, nor could she recall the name of a sister when
shown her portrait. She wandered aimlessly about the streets, bought food
which she allowed to spoil before attempting to use it and in a confused
manner poured kerosene on the floor and in the cook stove. She would
dress only in her night garments in which she would leave the house, and
she allowed herself to become very dirty, going, it was claimed, for more
than a year without a bath.
On admission a very unkempt, feeble and restless old woman, whose
clothes were filthy and in tatters, presented every evidence of the lack of
care. The heart offered no lesions, but there was a general peripheral
arteriosclerosis. Respirations were shallow and broncho-vesicular in char-
acter. Urinalysis showed the presence of hyaline casts. The left pupil re-
acted sluggishly to light, the right normal. Both pupils reacted to accom-
modation. Knee jerks not elicited. Romberg sign and a slightly ataxic gait
were present.
Mentally, the patient was not oriented. She was excited, restless, re-
sistive, and exhibited a marked impairment of memory for recent as well
as remote events. It was doubtful whether or not the patient comprehended
most of the questions asked her, whether this apparent lack of compre-
hension was due to impairment of hearing or to a sensory speech disturb-
i. She talked freely, but the speech content was often more irrelevant
than not.
The patient was in hospital for four years and five months. At first she
was more or less persistently noisy and restless, wandering about the ward
in aimless manner and frequently disturbing other patients by pulling at
their beds. This condition lasted for little more than a month. Later she
was quiet and tractable, usually remaining seated wherever placed. She
had to be dressed and undressed and cared for in every way. Her speech
content degenerated into a mere jargon, and it was quite clear that con-
prehension was practically nil.
Anatomical Diagnosis.-Increased thickness and density of calvarium,
ext, pachymeningitis, chronic hypertrophic leptomeningitis, ext, and internal
hydroceph., cerebral atrophy particularly pronounced of tempero sphenoidal
lobes and asymmetry due to the marked atrophy of left tempero sphenoidal,
advanced cerebral arteriosclerosis; pleuritis, lobar pneumonia; chronic in-
terstitial hepatitis; chronic interstitial splenitis; chronic interstitial nephritis
with cystic degeneration.
CASE XV.-W. S. H., No. 9378, a man fifty-six years of age had shown
a memory defect for some time but was able to continue at his work as a
laborer on a farm where he had worked many years. About ten days prior
4O
to admission he suffered an attack of influenza with which marked mental
Symptoms were associated. He was very restless at night, roaming about
the house, talking of his work and imagining he was doing it, going through
certain movements employed in farming. Finally he began to destroy his
clothing; he was disoriented and confused; apparently forgot the movements
employed in dressing and feeding himself; lost control of bladder and
rectal functions. Patient's mother died at the age of sixty-one from apoplexy.
On admission, a man in fairly well nourished condition, who looked
considerably older than his stated age, presented in his person the appear-
ance of neglect. His gait was wavering and unsteady, but not characteristic
of anything more than general weakness. A systolic murmur, best heard
at the apex, a full regular pulse and peripheral arteriosclerosis were present.
Respirations were shallow and save over the superior lobe of right lung,
broncho-vesicular in character. The pupils were slightly irregular in out-
line but equal, reacting sluggishly to light. No coöperation for accommo-
dation. Patient did not coöperate in tests for hearing and for same reason
test for smell, taste and touch were negative. There were no paralyses or
contractures. Tendon reflexes increased.
On the day of admission he was very somnolent, and could be aroused
only with difficulty. He was dull and apparently indifferent to his surround-
ings. His speech reactions were slow, data frequently incorrect, often a
logoclonic repetition of the last syllable of a word and, with increasing fatigue,
paraphasic. Some verbal amnesia was shown. He was disoriented, showed
marked defect of memory and was entirely without grasp on his surroundings.
The following day he was brighter mentally and for a while answered ques-
tions readily and in an orderly manner, although he was disoriented and
memory defect was apparent. He fatigued easily, then the emissive quality
of speech became thick and unintelligible and with it a paraphasia was asso-
ciated. A week later he became very noisy and restless and was confused
most of the time, remaining so until his death on the twelfth day after ad-
1111SS1O11.
Anatomical Diagnosis.-External pachymeningitis, herniae of Pacchionian
granulations through dura, chronic hypertrophic leptomeningitis, atrophy of
cerebral gyri, advanced cerebral arteriosclerosis; chronic endocardial thick-
ening; bronchopneumonia; chronic perihepatitis; chronic perisplenitis.
CASE XVI.-W. S. H., NO. 9249, was a man sixty-seven years of age.
When sixty-five he began to show a loss of memory up to which time his
general health had been good. He had been temperate in his habits and in-
dustrious. For two years he was very forgetful, at times acting as though
confused and was often incoherent in speech. During the two months prior
to admission the mental changes were more rapid in progress; he was often
untidy, noisy and restless, and had the idea that he was being pursued by
some one who wished to harm him.
On admission, a fairly well developed old man who appeared anaemic,
presented a rough, dry and Scrawny appearance of the skin, a systolic mur-
mur of the heart, general peripheral arteriosclerosis, and moist, diffuse
râles over the lungs. Pupils reacted to light and accommodation; patient
did not coöperate in tests for hearing, taste and tactile sense integrity. The
gait was unsteady, trepidant; muscular development and tone good. No
paralyses; no contractures, but a general tremor. Tendon reflexes elicited,
were not pathological. &
Mentally the patient was disoriented and apparently confused; at times
he gave expression to fears saying that he was pursued, and in consequence
was somewhat agitated. His speech content was prolix, often incoherent.
The next day he fabricated experiences, was restless and talked as though
replying to voices. He was in hospital four months and sixteen days, during
which time he was often confused, talkative and untidy. A week before
death a small abscess formed on the dorsum of the right foot, and about
the same time a lobar pneumonia developed from which he died on the seventh
day after its onset.
Anatomical Diagnosis.-Moderate cerebral atrophy, moderate cerebral
arteriosclerosis; acute degeneration of myocardium; lobar pneumonia;
hepatic congestion; splenic congestion; diffuse nephritis.
4.I
Analysis of Clinical Histories with Reference to Classification.
An analysis of the histories of these sixteen cases with reference
to clinical classification and evaluation of the associated gross and
histopathological lesions offers many difficulties. Although 62.5
per cent exhibited gross focal lesions of arteriosclerotic origin,
these coarse brain lesions must be considered as incidental, in so
far as direct relationship with plaques is concerned. In the suc-
ceeding group of cases which presented no plaques gross focal
lesions of arteriosclerotic origin were even more pronounced.
The great majority of the plaque cases on their clinical side and all,
save one, from anatomical considerations, must be classed with
the severer forms of senile dementia. If one takes the symptom-
complex characteristic of presbyophrenia confabulation, marked
impairment of memory, faulty reproduction, disturbance of judg-
ment and mental confusion—then three of the cases, all other
things considered, may be readily classed as presbyophrenia.
Dupré and Charpentier” have maintained that the symptom of
confabulation with the associated memory defect so prominent in
presbyophrenia is to be interpreted as evidence of a polyneuritis,
“affecting particularly the lower extremities, . . . an acute
polyneuritis with Korshkow’s syndrome later evolving into chron-
icity.” Nouët,” and Nouèt and Halberstadt“ do not share this
view. They call attention to points of similarity as well as to
points of difference in the two affections, laying especial stress on
age, sex, facial expression, garrulity, euphoria, mental confusion
and amnesia. Disturbance of consciousness and amnesia, they
claim, are more profound in presbyophrenia than in polyneuritic
psychosis. In the cases considered as presbyophrenia in this series,
alcoholism can be eliminated; but the possibility of a former neu-
ritis, although no history of such was elicited, cannot be entirely
excluded. Hammel” states that the presbyophrenic symptom-
complex may apear as a transitory syndrome in the course of
“simple senile dementia,” a view which the writer’s experience
favors. Cases II, VI, X and XII, on the whole, presented clini-
cally symptoms which best comport wth “simple senile dementia,”
although II and X showed at autopsy multiple gross focal lesions.
Case VIII suffered repeated cerebral insults during a period of
five years, motor residua and speech disturbance resulting. There
had been transitory periods of confusion of which the patient was
aware, but no considerable dementia, and throughout he pos-
sessed fair insight into his condition. He was of an apoplectic
family, his father having died from cerebral insult. Ordinarily
the case would be unhesitatingly classed as organic dementia
of arteriosclerotic origin. And yet, if we are to consider plaques
as evidence of senile dementia, or more properly speaking as an
42
index of Senile involution, is this an instance of precocious senility?
At any rate, the case falls short of a paradigm for “Alzheimer's
disease.” More nearly the type described by Alzheimer and
Perusini is Case XV, a man who for some time previous had
shown mental symptoms characterized chiefly by memory defect
and a steadily progressive dementia. During an acute exacerbation,
which supervened an attack of influenza, marked mental confusion,
ideational apraxia and speech disturbance of a sensory character
were present. At the autopsy the brain was within the range of so-
called normal weight, but there was atrophy of convolutions and
gaping Sulci in frontal and left tempero-sphenoidal lobes, thick-
ening and opacity of the pia over mesial surfaces of frontal lobes,
frontal and parietal convexity and superior surface of cerebellum.
The blood vessels were extremely tortuous and sclerotic, with
numerous atheromatous patches which imparted a beaded effect.
No gross lesions such as haemorrhage, softening or lacunae were
found anywhere. Microscopically there was no evidence of
Lissauer’s paralysis, ordinary general paresis or the lesions of
arterioslcerotic insanity made familiar by Alzheimer", Binswanger”,
Barrett” and others, but on every hand the general histological
lesions such as characterize the severe forms of Senile dementia
were encountered.
Case III perhaps was always an abnormal person. During
recovery from an attack of ptomaine poisoning a psychosis devel-
oped. The ptomaine poisoning and cardio-vascular disease from
which he suffered must be considered as possible exciting cause
for the psychosis; still the mental symptoms and anatomical find-
ings bore something of the involution stamp. The mental symp-
toms in Case IV were of comparatively slow development, but
certain rapidly developing sensory and motor Symptoms immedi-
ately supervening a supposed “sun stroke,” and in part persisting
to the end, were not adequately accounted for in coarse focal
lesions. Cases IX and XIV presented clinically marked intellec-
tual deficit, confusion and symptoms of Wernicke's aphasia, and
showed anatomically pronounced focalized atrophy of the left
tempero-sphenoidal lobe in one case and both tempero-sphenoidal
lobes in the other, atrophies which were not accounted for by
previous hæmorrhage, tumor and the like. Both brains could be
considered as examples of the “partial cerebral atrophy” to which
Pick,” and Rosenfeld” have called attention in published cases.
Grouping the cases according to the scheme outlined by
Wollenberg”, who recognizes two chief groups of senile dementia,
the first including cases with simple enfeeblement of intellect, the
second, of which presbyophrenia is a sub-group, having delirium
and hallucinations, all of the cases, then, with the exception of Case
VIII would fall into the Second category.
43
Since none of the sixteen brains were without evidence of
arteriosclerosis and three were without the macroscopic signs of
atrophy, the question of the relationship of atrophy to arterioscle-
rosis and the further question of the relationship of senile
dementia to brain wasting arises.
Age Incidence.—The age incidence of the plaque cases by a
decade is shown in the following table:
TABLE II
Decade. No. of cases.
6th. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I
7th. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
8th. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
9th. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Total cases I6
VI. THE CASES WITHOUT PLAQUES AMONG ELDERLY SUB-
JECTS DYING INSANE.
Clinical Abstracts.
CASE XVII.-W. S. H., No. 9221, spinster, seventy-nine years of age,
suffered a cerebral insult when sixty-one with resulting left hemiplegia. Since
this time, at intervals of about two weeks, there had been periods of un-
consciousness of from fifteen to thirty minutes duration. During the un-
conscious periods, stertorous breathing and muscular twitchings were pres-
ent. At times the attacks were more in the nature of delirium—mental con-
fusion and noisiness with considerable profanity. She slept little. Speech
content was not aphasic in character, but she was prolix, often incoherent,
and expressed delusions of ill-treatment on the part of relatives, who in
reality were extremely devoted. During this time she complained of the sun
shining on her constantly, and wished to be tucked firmly in bed for fear
of falling out. Ever since the shock, however, there had been a feeling of
insecurity against falls. Father of patient died of apoplexy at the age of
sixty-one; five maternal cousins were insane.
On admission, ancient left hemiplegia with contractures; left facial
paralysis; peripherial arteriosclersis; arcus seniles' and total blindness, al-
though patient insisted that she could see. When objects were placed before
her to name she had to pass her hand over them first before she could tell
what they were, but she usually named them correctly. The record of Dr.
David W. Wells, patient’s former oculist, for October 25, '99, reads: “cata-
ract of anterior capsule in right eye, but can read medium sized type. Left
eye examined under mydriasis, lens clear. March 6, 'O?, in right eye vision
still, .3 and with left eye was able to read nonpareil type. I doubt serious
anatomical defect of left eye.”
She comprehended well, but was talkative and noisy, and complained of
abuse on the part of the hospital personnel. The tenth day after admission,
patient was quiet and dull and had a temperature of 99.6 F. The next day
considerable difficulty in swallowing developed, the face was flushed, she
groaned frequently, and was aroused with difficulty. Death ensued.
Anatomical Diagnosis.-Increased density of calvarium, external chronic
pachymeningitis, internal pachymeningitis haemorrhagica interna (recent),
chronic hypertrophic leptomeningitis, marked cerebral hemiatrophy as result
of ancient destructive lesion of right insula, portions of putamen and globus
pladius, anterior half of T', the supramarginal and angular gyri
44
atrophy of the right tegmentum, right half of pons, yellowish softenings of
lobe involving , calcarine region, Advanced cerebral arteriosclerosis,
Sclerosis of left cross pyramidal tract of cord; , endocarditis, chronic
interstitial myocarditis; pulmonary congestion, bronchitis; moderate inter-
Stitial hepatitis; chronic interstitial nephritis.
CASE XVIII.-W. S. H., No. 8699, a man sixty-seven years of age, book-
keeper, a year previous to his admission to hospital had what is said to have
been an apoplexy which, however, was without residuals in the way of
paralyses—there was vomiting of a cerebral type, dizziness, double vision,
unsteadiness on his feet and a somewhat staggering gait. Diplopia persisted
for several weeks; the staggering gait did not improve. He lost his former
interest in things and would talk but little on subjects which did not per-
tain to his condition. For a few months immediately preceding admission
to hospital he became suspicious of persons who came to visit him, frequently
asking callers if they thought he was improving, and any failure to reply
promptly in the affirmative would be interpreted as a desire on the part of
the visitors to find out all they could about his affairs. He would stop
acquaintances, as well as strangers, on the street to ask if they thought he
was improving. Frequently he remained quiet for a long period as though
in deep thought, apparently oblivious to his surroundings. His memory for
the little daily happenings was very defective but for remote events good.
Two days before admission he was found during a heavy rain storm at the
back door of a neighbor's house unable to give his name, address, or utter
an intelligible sentence. When taken home he sat in a chair disinclined to
move, was resistive, threatening in his attitude, apparently suspicious, swear-
ing and calling to physician “get out,” “ain’t it a shame.” Next day he
was quiet and made no attempt to talk except when questioned and then
his replies were paraphasic. Two brothers of patient were insane.
On admission, a fairly well nourished old man who looked his age. The
first sound of the heart was accentuated, no murmurs, respiratory sounds
were normal, double inguinal hernia, peripheral arteriosclerosis, arcus senilis.
Pupils unequal, right larger, both reacting sluggishly to light and accommo-
dation. Swaying to Romberg; gait somewhat staggering and trepidant. K.
J. plus on both sides; Oppenheim and Babinsky phenomena elicited. Hear-
ing good. Integrity of taste sense could not be determined, likewise
ability for fine tactile discrimination. The aphasia which presented rendered
judgment of mental state difficult, but patient appeared at times confused,
at other times good natured. The aphasia was of the sensory type, for
sometimes there was almost a logorrhoea, although paraphasic in character
(verbal and literal) and frequently there was a verbal amnesia. He
recognized objects placed before him and indicated their uses, although he
seldom named them correctly. When fresh the word sense of simple language
(notion du not) was fair, but the patient fatigued easily and then it was
bad. Somatic orientation was very imperfect even when the patient was
fresh. There was agraphia for dictation as well as for copy, and alexia.
Reihen Sprechen, even for numerals was very poor. Perseveration was
marked. Although movements of the upper extremities were carried out
somewhat clumsily there was no motor apraxia in the sense of Liepmann.
At times he was very conscious of his defects which disturbed him exceed-
ingly, and was greatly pleased with his successes, but the quickness with which
he fatigued always rendered aphasic examinations unsatisfactory. . The
patient was in hospital a year and grew worse constantly, the speech con-
tent degenerating into jargon and incoherent paraphasic attempts at ex-
pression.
Anatomical Diagnosis.-Increased density of calvarium, chronic external
pachymeningitis, internal pachymeningitis haemorrhagica, chronic leptomen-
ingitis, cerebral atrophy, advanced cerebral arteriosclerosis, focal destruction
by hamorrhage (ancient) of left supramarginal gyrus, small old haemorrhage
in inferior portion of foot of post. central gyrus, granular ependymitis, chronic
endocarditis, aortitis, brown atrophy, of heart; chronic interstitial hepatitis;
chronic interstitial nephritis; enlarged prostate.
45
CASE XIX. —W. S. H., No. 7900, a man sixty-seven years of age, a broker,
began to show mental symptoms when sixty-three. He returned from a
successful business trip to a neighboring state, where he had gone a few
days before, apparently very tired. He went to bed and is said to have
slept for almost two days, after which he appeared quite dull. He however
continued for a time his usual work, but seemed to take no interest in it.
This was in June, 1907. Despite his lack of interest he continued at work
until the autumn, when he took a trip with his family to the Pacific coast.
While in the west he spent a great deal of money recklessly, and had numerous
wild schemes for going into business. At this time his mood alternated be-
tween periods of dullness and periods of excitement in which latter he was
talkative and irritable, at times threatening the lives of members of his
family. He also entertained vague fears of impending catastrophe to some
one of his family, particularly his son. Since the episode in June, 1907, there
had gradually developed a speech defect, first noted in an inability to recall
many words employed in ordinary conversation and by the time of admis-
sion to hospital a year later, he was markedly aphasic (paraphasia, verbal
and literal, literal agraphia, inability to comprehend complex sentences of
ordinary conversation, alexia, though not complete, inability to reneat from
memory, etc.). Contrary to his former habit he became very slovenly in
his personal appearance, ate his meals in a disgusting manner, used his
boots for a urinal, threw lighted matches about the house after lighting his
pipe and committed other acts of a similar nature which made it unsafe and
impracticable to care for him at home. The patient had always used alcohol
(daily), though, it was claimed, not excessively; otherwise his habits were
good and he had been a hard worker. An aunt of the patient was insane.
On admission, a small but fairly nourished man who looked older than
his reported age, somewhat untidy in appearance, with a general expression of
good nature, presented a right facial paralysis, a more or less fine general
tremor and exhibited a peripheral arteriosclerosis. There was an enlarge-
ment of the area of cardiac dulness, accentuation of the second sound of
heart; but no murmurs. Urinalysis revealed a chronic interstitial nephritis;
other trunk organs without special interest. The pupils were contracted,
reacted to accommodation, the right very sluggishly to light, the left stiff.
Station and gait good; deviation of tongue to left; tendon reflexes active; no
Babinsky.
Mentally the patient appeared confused; he was restless and wandered
about the ward in an aimless manner. His speech affection rendered difficult
a good mental examination.
The patient was in hospital two years and six months. He made no
improvement, suffered two cerebral insults in the course of his hospital
residence. Speech utterances degenerated into jargonic paraphasia, there
was entire loss of the word sense with complete agraphia and alexia, inability
to name objects and recognize their uses and to repeat words after examiner.
Anatomical Diagnosis.-Increased density of calvarium, congestion of
dura, chronic leptomeningitis, advanced cerebral arteriosclerosis, cerebral
hemiatrophy (slight), old lacuna involving putamen anteriorly, internal
capsule external capsule and some of the fibres of the insular, together with
numerous small lacunae and small old haemorrhagic areas in white substance
and basal ganglia on both sides; chronic endocarditis, aortitis, degeneration
of myocardium; chronic interstitial hepatitis; chronic interstitial splenitis;
chronic interstitial nephritis.
CASE XX.-W. S. H., No. 8287, a nurse sixty-one years of age, enjoyed
good health until about two years ago. About this time she had a fall in
a street of the shopping district of Boston, the result of tripping against a
curb stone. The day following, there was a bloody discharge from the left
ear and blood streaked expectoration. She was ill for a few days as the
result of the fall, but the illness was without serious consequence for she
was able to continue nursing. Eight months later she undertook the care of
an hysterical patient, a friend of hers, continuing the case, until the death
of her patient a year later. She felt keenly her friend's death and began
to worry quite a little. Two weeks after her friend's death she began to
46
have attacks of dizziness, her feet felt as though they were getting smaller,
and two months later a numbness in the right half of the face developed,
and in the corresponding half of the tongue there was a sensation as though
the member had been seared with a hot iron. When she brushed her teeth
they felt like a board. She drooled, occasionally bit the inside of her cheek
without knowing it, and vomited a great deal. About this time she com-
plained much of failing vision and visited several oculists for treatment.
A month later she began to have considerable difficulty in walking; she was
frequently forced to support herself against the walls of the room or pieces
of furniture to prevent falling. Everything in the room seemed to be going
round, consequently her gait was staggering in character. The condition
grew worse, so it was necessary to take to bed. Two months later, it was
noticed by friends that she fed herself in an awkward manner. She de-
veloped delusions that the food was “doped” and she was greatly depressed
over her health. A month later she became delirious and excited, and a
speech defect developed which from the description obtained must have
been a temporary verbal amnesia. No history of mental disease in the
family, but the mother of patient was a nervous woman who worried over
trifles. The patient herself was active and industrious but given to the
formation of pretentious plans which she never carried out.
On admission, a feeble, poorly nourished old woman presented, unable
to walk without support. The heart’s action was rapid, no murmurs, blood
pressure I44 mm Hg, peripheral arteriosclerosis, chronic gastritis and a
rectal prolapse presented. The pupils were equal and reacted to light and
accommodation, and there was clouding of both crystaline lenses. The pro-
truded tongue deviated sharply to the left and the right half was anaesthetic.
The upper and lower extremities could be moved freely, although with the
right hand finer movements were awkwardly executed. There was no dif-
ference in the hand grasps; both good. The patient could not walk unsup-
ported on account of vertigo, all attempts to do so resulted in staggering and
falling to the right. Tendon reflexes were active. Marked Romberg; no
Babinsky; no Oppenheim. Speech utterances were slow, indistinct and thick
in character. She comprehended all that was said to her and her replies
to questions were relevant. G
Mentally she was depressed over her condition, was generally nervous
and admitted that she worried. Five days after admission, considerable
moaning and groaning and projectile vomiting. A month later loss of rectal
and bladder control, persistent nausea and vomiting. She was confused and
often incoherent. When clear, a marked memory defect was shown. Four
months after admission, cerebellar attitude—she lay in bed with head ex-
tended and there was a degree of opisthotonous. The head was turned to
the right and attempts at flexion or turning in the opposite direction caused
great pain. Horizontal nystagmus and considerable somnolency were pres–
ent. Memory defect increased. She frequently said to nurse or physician,
*I can see only half of you.” The cerebellar attitude became more pro-
nounced, the patient grew worse, finally dying after a hospital residence of
three months.
Anatomical Diagnosis.-Increased density of clavarium, congestion of
dura, chronic leptomeningitis, atrophy and flattening of cerebral gyri, atrophy
and marked softening of right cerebellar hemisphere as the result of
haemorrhage, congestion of cord, osteomata of spinal pia; chronic
endocarditis; pleuritis, broncho-pneumonia; congestion and fatty infiltration
of liver; splenic congestion; gastro-enteritis; moderate interstitial nephritis;
moderate interstitial pancreatitis; senile involution of reproductive organs.
CASE XXI.—W. S. H., No. 6589, a man seventy-one years of age, who
although always of a nervous and excitable temperament, had enjoyed rea-
sonably good health until the age of sixty-three. At this age he had what
was described by friends as an attack of “nervous prostration,” following a
long period of hard work and some worry over his affairs. He did not
improve but grew worse from year to year. Formerly a man neat, in his
personal appearance, of good habits and circumspect, in morals, he became
careless in dress, extremely untidy in his habits and morally unendurable.
47
He annoyed people by long calls at their houses or business places, en-
gaging them, particularly the women, in interminable conversation. He
would stop women, entire strangers, on the street, inquire as to the number
of their children, put his hands on them, remark on their physical develop-
ment and offer indecent proposals. The same he did to girls as young as
twelve years. Frequently he went about the house nude and would make
his appearance in this manner when visitors were present. He was often
irascible, destroying furniture and lighting fixtures whenever he felt they
were in his way. On two occasions he had handled his wife violently, and
kept a piece of iron pipe in his bedroom to defend himself against burglars
and other intruders. He would sleep on the floor instead of on a bed, and
order the light on the piazza to be kept burning all night “to light the weary
traveler on his way” when there was a street lamp opposite his house. He
insisted on undressing his wife at night and anointing her with crude
petroleum, etc., and maintained that his near neighbor was the vice-president
of the United States. He was improvident with money, often throwing
pennies away, yet complaining that relatives were not aiding him with funds
to supply his needs. At rare intervals he was quite rational and orderly.
He was often untidy about the house, using the kitchen sink as a urinal,
etc. His mother was considered an eccentric, a sister likewise. A nephew
is an epileptic.
On admission, a well developed, well nourished old man who looked
older than his reported age, presented a marked senile trepidant abasia,
periphéral arteriosclerosis, increased heart's action and a chronic interstitial
nephritis as shown by urinalysis. Vision was defective, opacity of both lenses,
pupillary reaction sluggish to light and accommodation. Hearing defective,
most marked in left ear. Smell, taste and tactile sensations were apparently
unimpaired. Tendon reflexes active; no Babinsky.
Mentally the patient was oriented, memory for important events in his
life. No insight, saw no good reason for sending him to hospital, but thought
he knew who was responsible. He comprehended what was said to him,
talked freely but was very prolix. He cried easily without apparent good
cause and his general mental attitude was very childish. Later he showed
a tendency to disturb the ward by loud talking during the night. He had
several dizzy attacks accompanied by nausea, but these were never asso-
ciated with loss of consciousness. He wrote many incoherent letters and
frequently had attacks of unprovoked laughter or crying. Eleven months
after admission, while on his feet one day he suddenly became dizzy and
unsteady. He called out for assistance saying he did not dare to move, fol-
lowing which he was much confused. He would frequently leave his bed
to wander about the ward in an aimless manner. After this attack memory
deteriorated rapidly, particularly for recent events. There were frequent
periods of untidiness. He failed gradually but constantly, finally dying
twenty months after admission to hospital.
Anatomical Diagnosis.--Thickened calvarium, adherent dura, congestion
of meninges, general pial opacity, congestion of brain, atrophy of cerebral
and cerebellar convolutions, arteriosclerosis of cerebral vessels; congestion
and atrophy of spinal cord; thickening of mitral cusps, interstitial
myocarditis, atheroma of aorta and coronaries; hypostatic congestion of
lungs; congestion and interstitial Splenitis; chronic interstitial nephritis;
gastritis; decubitus of buttocks, trochanters and left interior malleolus;
diverticula of bladder.
CASE XXII.-W. S. H., No. 8516, a woman, widowed, formerly a nurse,
is said to have enjoyed good health until the age of seventy-five. At this
time she began to show decided memory defect, general fussiness and physical
feebleness which precluded earning a livelihood, by her own efforts as
formerly. Without means and owing to increasing physical and mental feeble-
ness, she had been supported for more than a year from certain charitable
funds. In the year prior to admission memory, defect had grown very pro-
nounced; there were periods of confusion and she had shown a tendency
to stray away. Once she left her boarding house and was gone over night
48
and when returned the next day, after having been picked up on the street,
her head was cut and bruised. She could give no account of the injury.
She shifted her boarding house several times, finding it difficult to get on
with landladies. While at her last boarding place she imagined that the
young men lodging in the house were in love with her and on one occasion
attempted to get in bed with one of them who had treated her kindly and
befriended her in many little ways. Family history as obtained is meagre
and unimportant.
On admission a feeble old woman presented. She was poorly nourished,
exhibiting marked peripheral arteriosclerosis, a deformity of the left wrist
(improperly united fracture), numerous cloasmae on face and hands, senile
trepidant abasia, general senile tremor, a systolic cardiac murmur, defective
sight and hearing, and impairment of the sense of smell. The pupils re-
acted promptly to light and accommodation; arcus senilis; tendon reflexes
active.
Mentally she presented a good-natured indifference to her surroundings,
was faultily oriented, and had defective memory for important events, re-
mote and recent. She immediately adapted herself to ward surroundings
and except for occasional untidiness and a general senile fussiness was quiet
and gave no trouble.
Patient was in hospital for a year, during which time she suffered several
attacks of diarrhoea which weakened her. All the while she grew more
childish, and memory defect increased. Finally difficulty in Swallow-
ing developed during an attack of broncho-pneumonia. Temperature
rose to IO5° F., the heart's action gradually weakened. Death.
Anatomical Diagnosis.-Increased density of calvarium, pachymeningitis
externa, leptomeningitis chronica, cerebral atrophy and asymetry of moderate
degree, advanced cerebral arteriosclerosis; endocarditis, aortitis; pleuritis,
pulmonary congestion, broncho-pneumonia; hepatic congestion; splenic con-
gestion; focal congestion of gut; chronic interstitial nephritis, uterine
fibroma.
Multiple old lacunae (int. cap. left) and basal gang, corona.
CASE XXIII.-W. S. H., No. 8306, a woman seventy-three years of age,
began to have attacks of dizziness at the age of seventy-one which increased
in frequency. Her memory for the two years preceding admission to hos-
pital was decidedly defective, especially for recent happenings. She had often
appeared depressed and suffered considerably from insomnia. She gave as
a reason why she could not sleep that the parties held at the house late
into the night (hallucinations) had kept her awake. She was depressed
because of the recently acquired intemperate habits of her son (delusion).
She was occasionally confused and talkative, the speech content rambling
and incoherent.
On admission an emaciated feeble old woman, who looked older than her
reported age, presenting general coarse tremors, marked peripheral
arteriosclerosis, rapid and irregular heart's action. The pupils were dilated
and reacted promptly. The hearing was greatly impaired. Knee jerks were
active, other tendon reflexes sluggish, gait unsteady and extremely trepidant.
Mentally the patient was disoriented, showed a marked memory defect for
recent happenings was without insight, and claimed that people had inten-
tionally annoyed her. She seemed surprised when told that the hospital
was an institution for the care of the insane, replying “I must leave im-
mediately, I am not insane. How could my nephew, do this? I have
done so much for him,” emotionally disturbed meanwhile. She admitted
auditory hallucinations.
A month later loss of bladder and rectal control and increased memory
defect. Although claiming to have been abused by the hospital personnel
there was for the most part a good-natured indifference to her surround-
ings. Two months after admission (during summer) diarrhoea with great
prostration; recovery. Eleven days later sudden development of difficulty
deglutition, weak heart's action; death. tº e - ©
Anatomical Diagnosis-Chronic leptomeningitis, atrophy of cerebral
49
gyri, cerebral arteriosclerosis; moderate cardiac atrophy, atheromatous
thickening of endocardium; pleuritis, hypostasis; Glissonitis; moderate in-
terstitial splenitis; moderate interstitial change of kidneys, extensive decubitus
Over sacrum and buttocks.
CASE XXIV.-W. S., H., No. 8751, a man seventy-five years of age con-
. whose previous history nothing is known, died after three days in
OSp1ta.I.
On admission, an emaciated, very feeble old man unable to walk (weak-
ness) presented extensive trophic skin lesions over the right deltoid, lower
portion of back and gluteal region. The heart's action was weak, arythmic,
Sounds muffled. Fair pulmonary resonance, but rāles were present. Pupils
reacted to light; patient did not coöperate in accommodation tests. Opacity
of crystaline lenses; arcus senilis. All tendon reflexes weak; no Babinsky.
Mentally the patient presented alternating periods of confusion and clear-
ness. He was disoriented and memory was very defective, a condition into
which the patient had some insight for he often made excuses for his poor
memory on the ground of age. He slept a great deal and when awake paid
practically no attention to his surroundings. When admitted there was a
diarrhoea which persisted to the end.
Anatomical Diagnosis.-Increased density of calvarium, external
pachymeningitis, hydrocephalt's interna et externa, cerebral arteriosclerosis,
multiple old punctate haemorrhagic areas in head of caudate nucleus and pons,
moderate cerebral atrophy; parenchymatous degeneration of myocardium,
peripheral arteriosclerosis; chronic pleuritis; gastritis, enterocolitis; chronic
interstitial nephritis with cystic degeneration of kidneys, multiple and ex-
tensive trophic lesions of skin.
CASE XXV.-W. S. H., No. 8589, a man, retired farmer, eighty-five years
of age had enjoyed general good health until about his eightieth year. He
had given up active work and was beginning to be feeble, his sight was poor
and memory defect was noted, all of which have increased in the inter-
vening years. Although he had shown a tendency to stray away, and at
times mixed his ideas when talking, for the most part he had been dull and
quiet, sleeping a great deal. During the year prior to admission to hospital
restless periods had been more frequent and he had to be constantly watched
that no harm should come to him.
On admission, a feeble old man who looked his age, presented perpheral
arteriosclerosis, arcus senilis, a slightly accentuated second sound of the
heart and slight dullness over the apex of the left lung. Vision (presbyopia)
and hearing were impaired. There was a general senile tremor and the
gait was markedly trepidant. The tendon reflexes were elicited with difficulty.
Mentally the patient appeared confused. He was disoriented, cried when
talking of his family and showed a marked memory defect for the grossest
events, remote as yell as recent. His attention was difficult to hold. The
speech content was prolix and often incoherent. He was quite indifferent
to his surroundings and when told he was in hospital remarked it might do
him good to remain here “for a little toning up.”
Patient was in hospital a little more than three months, confined to bed
all the while on account of general feebleness, showing throughout pronounced
memory defect, finally dying from an intercurrent lobar pneumonia.
Anatomical Diagnosis–Increased density of calvarium, adherent dura,
pachymeningitis haemorrhagica interna, leptomeningitis chronica, atrophy of
cerebral gyri, cerebral arteriosclerosis; degen, of myocardium (acute
myocarditis), endocarditis; chronic perihepatitis, hepatic congestion, fatty
infiltration; right lobar pneumonia and exudative pleurisy; colitis; interstitial
pancreatitis with cystic degen. of gland; chronic interstitial nephritis; scalp
wound of right occipital region.
CASE XXVI.-W. S. H., No. 5486, a woman, widow, seventy-eight years
of age, admitted to this hospital when sixty-two where, she had been , ever
since. She was always a peculiar character—self willed, lacking in persistive
power, odd–but save for an occasional attack of tonsillitis, last one eight
years before admission, and a fall from a street car four years previous,
50
slight injuries resulting, she had suffered no serious illness for more than
, thirty years. Although a good seamstress she was seldom employed at the
same place twice on account of her oddities, so for many years up to two
years preceding her admission she had practiced as a professional medium.
For several years it had been noticed by friends that she related imagined
experiences as facts, and this aside from her mediumistic practices. Where
She lodged the landlady had noticed that she frequently acted very queerly,
and on one occasion about two years prior to admission she went to her
sister's home late at night, claiming to have heard the sister calling for her.
During the three weeks before coming to hospital she had been far more
talkative than usual, mostly about happenings of many years ago and about
almost every one she ever knew.
li ºpaternal uncle was insane. No other family history of importance
el1Cited. it
On admission, she was well preserved for her age and was in good
physical condition. Mentally she was somewhat excited, exhibiting periods
of apparent confusion. In the clear periods she resented being brought to
hospital, Spoke in flowery language and was inclined to be dramatic. Memory
for recent events was poor. Later she gave evidence of auditory hallucinations,
was irritable, made many complaints and developed ideas of personal im-
portance, claiming that she was Queen of England, etc. She soon, how-
ever, adjusted herself to hospital regulations and was helpful in the sewing
room. Three years later she was less exhilarated and more inclined to de-
pression. With the years she was contented at the hospital and quite in-
different. She remained in apparent good physical condition for about seven
years when one day she announced to her hospital friends that she did not
expect to live much longer, at the same time writing her will. She became
irritable and markedly depressed. Examination revealed a grayish cauli-
flower-like growth involving vulva and anus which was beginning to break
down. The growth progressed rapidly and broke down (carcinoma). Death
supervened a month later.
Anatomica Diagnosis.-Increased density of calvarium, oedema of pia,
atrophy of cerebral gyri, moderate hemiatrophy of cerebrum, advanced
cerebral arteriosclerosis; thickening of mitral and aortic cusps, atheromatous
degen. of endothelium in ascending aorta; chronic adhesive pleuritis; fatty
infiltration of liver and congestion; splenic congestion; cystic degeneration
and anaemic infarcts of kidneys; introitus vaginae, labia majora et minora
seat of carcinoma.
CASE XXVII.-W. S. H., No. 7099, a man seventy years of age, never
a healthy person, for twenty years prior to admission had been constantly
under the care of physicians and had done no work. He had complained
of dyspepsia and general weakness. He had always been contrary, irritable
and impulsive and bore a reputation for oddness. When sixty-six years
of age, his family began to notice that his memory was poor and that he
was becoming childish. About two months before admission he had gone
to the country and while there became quite restless and was frequently
excited. While in the train returning to his city home he had what was
described by friends as a “slight shock,”—projectile vomiting and a marked
but suddenly developing mental confusion, during which he talked a great
deal in an incoherent manner. Following this episode and up to the time of
his admission, he showed considerable restlessness, was often confused, and
lost himself easily in formerly familiar surroundings.
On admission there was distinct evidence of peripheral arteriosclerosis,
arcus senilis, cardiac hypertrophy, increased and irregular heart’s action and
a chronic interstitial nephritis as revealed by urinalysis. The pupils reacted
promptly to light and accommodation tests. Hearing was impaired, most
marked in left ear.
Mentally the patient was confused and restless; comprehension poor.
He laughed when asked questions. W
The following day he gave with fair accuracy, the data for his chart.
He talked freely of places in Boston with which he was familiar, claiming
to be in business there (romance). Remote events were described in detail,
5I
but for recent events he admitted a poor memory. “There has been some
indefinite depression which I could not outgrow,” he said.
Soon after, and throughout, there were alternating periods of confusion
and periods with a fair degree of mental clearness. All the while memory
defect for remote and recent events was progressive and he grew more child-
ish in his manner, giving utterance to many hypochondriacal complaints and
was occasionally untidy, finally dying suddenly a little more than three years
after admission. *
Anatomical Diagnosis.-Cerebral congestion, chronic leptomeningitis, at-
rophy of cerebral gyri, granular ependymitis, cerebral arteriosclerosis, cardiac
hypertrophy, endocarditis, thrombus of pulmonary artery; interstitial
hepatitis; splenic congestion; gastritis; interstitial nephritis, cystitis, pros-
tatic hypertrophy.
CASE XXVIII.-W. S. H., No. 8931, a man seventy years of age, formerly
a farmer, always of a retiring disposition suspicious of the motives of others.
egotistic and overbearing, nevertheless of poor judgment, began to have
difficulty with his hearing twelve years ago, in consequence of which he
became more and more isolated. For quite a long period (several years)
he had heard noises in his head but these were correctly interpreted as the
result of his ear disease. Of late, however, these noises had been falsely
construed. During the ten years prior to admission patient is said to have
had several “mild shocks,” but data concerning these are indefinite. Four
years ago he met with an injury to his right hand, resulting in the loss of
four fingers. The mental and physical shock from the injury was great and
ever since there had been progressive mental and physical failure. Of
late, he had been actively hallucinated (auditory) and was much disturbed
in consequence, alarming the neighborhood with appeals to be saved from
murder. He had shown a tendency to stray away, collect useless articles
and in a confused manner would burn old newspapers indoors to drive away
evil spirits. He had lost all sense of modesty.
On admission, a well-developed old man, seventy years of age, somewhat
obese, tidy in appearance, but rather decrepit. There is a deformity of the
right hand as the result of a loss of four fingers. He walks in a halting,
trepidant manner and is slightly ataxic. There is a left facial paralysis with
ptosis of the left eyelid. The pupils are contracted, equal, sluggish to light
and do not react to accommodation tests. The tongue when protruded shows
a coarse tremor and deviates to the left. Deafness is marked, apparently
complete in the left ear and with the right ear the patient can hear only
the shouted voice. Respirations are shallow, heart sounds faint but rhythmic
and of normal frequency. No cardiac murmurs. Right K.J. active, left
absent, Babinsky and Openheim phenomena present on right side, plantar
reflex on 1eft side normal, Coördination tests poorly executed. A history
of syphilitic infection fifteen years previous was elicited.
Mentally there appeared to be considerable dulling and marked emotional
instability—crying without any adequate external cause. The speech was
slow, thick and at times quite indistinct. The patient was entirely without
insight into his condition; he thought he was being persecuted by his brother,
and the reasons given for this belief were quite puerile if not silly. While
he was at first quiet, there soon developed nocturnal restlessness and a dis-
position to become noisy. Eight days after admission he suddenly became
unable to rise from a chair in which he was sitting. There was no loss of
consciousness but his increasing feebleness made it necessary to confine him
to his bed. Three weeks after admission a facial erisypelas developed which
was followed, two days later, by a broncho-pneumonia from which he died
ten days after onset of latter, a month and six days after admission to
hospital.
"intomical Diagnosis.-Increased density of calvarium, external pachy-
meningitis, focal proliferative pachymeningitis, chronic leptomeningitis,
atrophy of cerebral gyri; endocarditis; pleuritis, broncho-pneumonia; hepatic
congestion; splenic congestion, perisplenitis, interstitial splenitis; interstitial
nephritis; deformity of left hand.
(Focal luetic changes.)
52
CASE XXIX.-W. S. H., No. 8646, a spinster, sixty-six years of age,
suffered an attack of insanity at the age of forty-seven which lasted for
Seven years. Recovery with defect. All her life she had been more or
less eccentric and had masturbated persistently. Mother of patient and ma-
ternal grand parents died of cardiovascular disease, one relative was intem-
perate, another epileptic. *
The salient clinical features on admission were peripheral arteriosclerosis,
tachycardia, goitre, chronic proliferate arthritis of fingers and knees,
high arched palate, exaggerated deep reflexes, slight Romberg, general senile
tremor, Senile trepidant abasia and moderate spinal curvature (kyphosis).
Mentally there were mild depressions, a tendency to assume affected atti-
tudes, expression of indefinite fears and numerous hypochondriacal symp-
toms; good Orientation and retention of school knowledge and a fair memory.
The patient easily adjusted herself to hospital surroundings. After two and
a half months in hospital, periods of confusion, restlessness and loss of
bladder and rectal control appeared. Three months later cerebral insult dur-
ing the night. When seen next morning she was confused, heart's action
weak and she groaned a great deal. She could not talk but when aroused
seemed to comprehend. Slight improvement followed, but speech content
was limited to “yes” and “no,” “well, I want to.” Aphasic protocols made,
showed that there was good comprehension of spoken language; she recog-
nized and indicated the uses of objects shown, pointed them out when re-
quested and could do the same for colors. She could write neither from
copy nor dictation. She fatigued easily and frequently became confused
during examination. Following the slight improvement after the insult there
was gradual but persistent failure. Death seventeen days later from an in-
tercurrent lobar pneumonia.
Anatomical Diagnosis.-Congestion of dura, chronic leptomeningitis,
frontal lobe atrophies, advanced cerebral arteriosclerosis, cerebral
myelomylacia, multiple coarse brain lesions in left cerebrum and pons;
chronic endocarditis, degeneration of myocardium ; lobar pneumonia; hepatic
congestion and chronic interstitial splenitis; multiple infarcts of kidneys;
small sub-serous uterine fibromata. -
CASE XXX.-W. S. H., No. 8759, a man sixty-two years of age, suf-
fered a cerebral insult at fifty-two, prior to which he had enjoyed good
health. There was apparently good recovery. Six years later he had a
second “shock” and since had never been well, physical and mental failure
had been marked. His memory became impaired, he was often irritable,
restless and had alternating periods of excitement when he was violent and
threatening, and periods of dullness during which he sat quietly staring
vacantly into space. He had been hallucinated (visual) and contrary to
former habits, became slovenly in person and untidy.
On admission, a fairly well nourished man, who looked older than
his reported age, presented peripheral arteriosclerosis, increased heart’s
action and a trepidant abasia. The pupils were unequal and reacted
promptly to light and accommodation tests. The tongue deviated to the
right. Right K. J. increased; right ankle clonus. Other tendon re-
flexes elicited. No Babinski; no Oppenheim. General tremor of head;
choreic movements of the neck; Romberg sign.
Mentally the patient was disoriented, showed a memory defective for
the grossest events, remote and recent. He cried when speaking of his
family, and his enunciation at times was very defective, but he seemed to
comprehend when addressed; there were also short periods of confusion.
He later showed some restlessness, frequently fabricated experiences, showed
poor rentention and was often untidy. Cºn account of feebleness he was
in bed all the while, apparently fairly contented with his surroundings.
Death after a hospital residence of three months and two weeks.
Anatomical Diagnosis.-Pachymeningitis haemorrhagic interna, lepto-
meningitis chronica, atrophy of cerebral gyri, cerebral alteriosclerosis,
multiple softenings and old apoplexies; cardiac hypertrophy, aortitis;
pleuritis, broncho-pneumonia; hepatic congestion and hypertrophy; gas-
tric ulcer; interstitial nephritis. -
53
| Case XXXI.-W. S. H., No. 2829, a woman sixty years of age had a
history of epileptic attacks since her fifteenth year. At twenty-eight, insane
and had been ever since. In hospital since 1894, at which time she was
very noisy, threatening and gave evidence of visual and auditory hallucin-
ations. During her hospital residence frequent grand mal attacks, as many
as forty-seven during a single month are recorded. Repeated attacks of
excitement following a series of convulsions; a marked dementia during
the five years preceding death. Following a severe epileptic seizure four
years before death, development of an umbilical hernia. Death twelve years
after admission from a strangulation of hernia noted above. During the
last year she never attempted to walk on acount of a marked unsteadiness
and a gait which was staggering in character. Dementia had been marked.
Anatomical Diagnosis.—Cerebral congestion and arteriosclerosis; cardiac
hypertrophy; pulmonary congestion and pleuritis; moderate interstitial he-
patitis; splenic congestion; strangulated hernia; interstitial nephritis; cystic
'degeneration of right ovary, uterine fibroma.
Case XXXII.-W. S. H., No. 6851, a woman eighty-five years of age,
when eighty was bitten by a mad dog, up to which time she had enjoyed
good health. After the accident with the dog she was ill in bed for two
weeks, but no evidence was elicited in the history suggestive of rabies, but
since that time she had failed physically and mentally. On an average of
about once a month during the two years prior to her admission to the
hospital she had been excited and delirious; her memory was poor; she was
frequently untidy; and had showed a tendency to roam around aimlessly.
A year prior to admission she suddenly lost the use of both lower extremi-
ties and of her left hand, (apoplexy), but this was not permanent for on
admission she could walk. Six months later aphasic disturbances set in
and for the six weeks prior to admission she had been unable to utter an
intelligible sentence.
On admission a rather small, very untidy and neglected old woman,
who, when assisted, walked in a very trepidant manner, the gait shuffling
in character and wide-spread. Heart's action weak and rapid, bronchitis,
and evidence of chronic interstitial nephritis. . General peripheral arterio-
sclerosis. Both pupils contracted and reacted sluggishly to light, the patient
not coöperating for accommodation tests. Tests for hearing, unsatisfactory,
although patient appeared to hear. Tendon reflexes elicited, the knee jerks
increased. Left-sided Babinski.
Mentally the patient was dull and frequently appeared confused. She
seemed to understand simple questions addressed to her, but all attempts to
reply resulted in an unintelligible paraphasia or in jargon, a condition which
did not improve at any time during her hospital residence. On account of
her inability to get about well she was kept in bed, although she frequently ,
left bed to roam about the ward in a confused and aimſess manner; she
never seemed able to find her bed having once left it. Later she was unable,
because of increasing feebleness, even to get out of bed, and periods of con-
fusion were more frequent. In the clearer priods she seemed to understand
simple conversation addressed to her and appeared greatly pleased when the
physician stopped to talk to her. A suppurating gland of the neck developed
two months prior to death which never healed, and two weeks later gangrene
of the left foot. While she was in hospital she emaciated considerably, finally
dying after hospital residence of three years and three months.
Anatomical Diagnosis.-Increased density of calvarium, congestion of
dura, chronic hypertrophic leptomeningitis, atrophy of cerebral gyri and cere-
bellar foliae, general congestion of brain, advanced arteriosclerosis of cerebral
vessels; cardiac atrophy (?); anthracosis, atelectasis, pleuritis, moderate pul-
monary congestion; moderate interstitial nephritis, senile atrophy of the
reproductive organs; small wound of neck. (Multiple old haemorrhagic soft-
ening of basal ganglia, both sides and in white substance.)
Case XXXIII.-W. S. H., No. 5203, a woman eighty-five years of age
developed the symptoms of Paget’s disease (osteitis deformans) twenty-nine
54
years ago. A short while before the onset of the bone disease she had acci-
dentally fallen through a trap door into the cellar. There was no history of
fracture following the fall, but since that time she had never been quite well.
Prior to the fall, save for inordinate modesty and a tendency to profuse
Sweating about the head, she was considered a normal person. Soon after
the accident, she began to complain of pain in the back and knees. So severe
was the pain that she could not take even a short walk without becoming
prostrated. This, however, did not last long, for the pains became less
Severe, finally disappearing. After this her legs began to curve outward, her
hips had the appearance of spreading and there was a curvature of the upper
portion of the back (kyphosis cervico dorsalis). There was an interval of
ten years before the sister, who gave the information, again saw the patient.
At this time the increase in the size of her head was striking and it was noted
that she was much shorter in stature than formerly. In the meanwhile the
thyroid gland had enlarged and there was considerable difficulty in breathing
after the slightest exertion—going up stairs, taking a short walk, etc. She
was very weak and it did not seem as though she would live long. Not long
after this there was a severe illness during which there was free watery (?),
discharge from mouth and throat. Her head, however, was no smaller after,
recovery from this illness, which from its general character was considered an
attack of influenza. After recovery from the grippe she began to do and say
queer things, continually growing worse during a period of nine months. In
this time she was often confused, noisy, hallucinated and complained of pares-
thesias—worms crawling over the body, etc.
On admission, a rather feeble old woman, presented an enlarged head with
triangular shaped face, base upward, enlargement of thyroid, particularly
right lobe, cervico-dorsal kyphosis, a broad pelvis, lower extremities curved
outward and forward. Heart's action was rapid and weak, pupils dilated and
sluggish. Patient did not coöperate in other tests. The voice was peculiarly
rasping in character, hoarse and rattling. She was noisy, her speech content
was often incoherent, and she thought the food and drink given her were full
of worms. In hospital eight years, in bed most of the time, untidy, noisy
when anyone was near, thought she was being denied the comforts due her and
was occasionally restless, getting in and out of bed. A year before death
she had a fainting spell during which the heart beat was scarcely audible,
but recovered her usual condition in a few days. A year later, during an
attack of bronchitis she suddenly collapsed, dying ten minutes later.
Anatomical. Diagnosis.-Osteitis deformans of calvarium (Paget’s dis-
ease), cerebral atrophy, cerebral arteriosclerosis; chronic endocarditis of
mitral and aortic valves; broncho-pneumonia; hypertophy and calcareous
degeneration of thyroid; chronic interstitial nephritis; osteitis deformans of
spinal column and femurs. -
Analysis of Clinical Abstracts of Non-plaque Cases with Reference
to Classification.
A survey of the cases without plaques from elderly persons
dying insane shows that a large percentage (seven cases) falls
readily into the clinical group of arteriosclerotic insanity. Two
cases (XXVI and XXVII) may have been originally dementia
praecox upon which arteriosclerotic changes were later super-
&mposed, one without and the other with coarse focal lesions.
Cases XXIII and XXV, even XXII, despite the multiple gross
focal lesions, might be considered senile dementia and while not
wholly “simple senile dementia” nor cases of presbyophrenia, fit
in Wollenberg's second category.” Case XXXII offered difficul-
55
ties in classification. Sensory and motor symptoms were accounted
for in coarse brain lesions of arteriosclerotic origin. Mental
failure, however, did not set in until the eightieth year; even then
psychical shock played no inconsiderable rôle. Case XXXI was
an epileptic with history of seizures during a period of fifty-four
years. In the hippocampal region histological lesions were plenti-
ful. Striking features were great numbers of amyloid bodies
(as many as seventy in a single oil immersion field) varying from
the size of a red blood cell to a large lymphocyte of the blood
Stream, and colonies of large fibre-forming glia cells. Occasionally
an amyloid body would present a fibril or fibrils wrapped around it
in much the same way one would wind a string loosely around
a spool, in quite the same manner as pictured and described by
Alzheimer". A single amyloid body, or a group of them, showed
not infrequently an encapsulation with small glia cells and nu-
merous fine glia fibres. The amyloid bodies were confined to the
first and second cortical laminae, mostly to the first. While no
plaques in the sense of the structures described in a subsequent
section were found, the similarity of the reactive gliosis and the
position of corpora amylacea, always as it seems in dilated meshes
of the glia reticulum, suggest an analogous origin for both
processes.
One case, XVII, clinically and anatomically post apoplectic
dementia, presented, on microscopical examination, in the gray
and white substance at the periphery of a large recent softening
of the left occipital lobe, numerous large cells of a phagocytic
character (Abraumgellen of the Germans). These cells were free
in the tissue, and the adventitia and perivascular lymph spaces
of blood vessels in the vicinity were crowded with them. The
cells without the vessels were often grouped in colonies and
many gave the impression of having coalesced (Fig. I3). These
groups of phagocytic cells do not appear at all comparable to
the plaques dealt with in this paper. Bickel,” however, has
described a like condition as a variety of plaque. In this case
they were interpreted as the usual reaction following any acute
destruction of nervous elements.
Age Incidence.—The age incidence of this group of cases is
shown in the following table:
TABLE III.
Decade. No. of cases.
7th. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8th. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
9th. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Total cases 17
56
VII. MATERIAL FROM ELDERLY SUBJECTs witHouT PSYCHOSIs.
Six cases constitute this group, but one of them dying at the
age of fifty-four cannot be considered, in a strict sense, as a case
of Senility. The case was added for the reason that in the au-
topsy protocol “cerebral sclerosis” had been noted. The remain-
ing five cases were eighty, seventy-eight, seventy-five, seventy-
two and sixty-eight years of age respectively at the time of
death.
CASE XXXIV, a man, eighty, without psychosis, showed at
autopsy pulmonary tuberculosis, chronic appendicitis, hydrocele
and marked Oedema of the brain. Small pieces of brain fixed in
formalin were available from the following areas: a six-layer type
of cortex—probably frontal—antr. central cortex, corpus striatum
and hippocampal gyrus.
In Sections from all of the blocks of tissue, plaques were
found in goodly number, but most numerous in sections from the
hippocampal region (Fig. 3). Alzheimer's intracellular degenera-
tion of neurofibrils was seen in some cells of the large pyramidal
layer of Ammon's horn, missed in the other regions studied. The
general histological changes of this case, so far as demonstrable in
Bielschowsky sections and by Herxheimer’s scarlet method for fat,
were essentially those as appeared in cases of senile dementia
reported in this paper.
CASEs XXXV, XXXVI, XXXVII, XXXVIII, XXXIX, at
autopsy, gave evidence of cerebral arteriosclerotic disease—
atrophies, haemorrhages, multiple focal softenings and the like.
In none of the portions of brains available from these cases
were plaques found. The histological changes were more of the
character of some of the cases with purely arteriosclerotic al-
terations.
CASE XXXIV of this series, the case of Oppenheim, and
cases reported by Simchowicz indicate clearly that plaques may
be present without psychosis; and, if the thirty-one-year-old tabetic
of Alzheimer be excepted, may be considered as evidence of senile
involution. In the same manner that general histological changes
of senile dementia are intensified over those of senile involution,
so are plaques, as a rule, more numerous in Senile dementia than
in simple normal senile involution.
VIII. RESULTS OF EXAMINATION OF MATERIAL OF FIFTY
YOUNGER SUBJECTs DYING OF VARIOUS MENTAL
DISEASES.
In this supplementary group there were twenty-seven cases
of general paresis, four of manic-depressive insanity, including a
case of involution melancholia, three of cerebral lues, one of micro-
57
cephalic idiocy, two of tuberculous meningitis, one of purulent
menigitis (streptococcus infection from middle ear) in a katatonic
dementia praecox thirty-five years of age, two of brain tumor, one
of psychosis associated with anaemia and multiple degenerations of
spinal cord, five of chronic alcoholism, four of dementia praecox
and one of marked cerebral arteriosclerosis in a woman fifty years
of age with a bad alcoholic history, dying of extensive haemorrhage
into the left lenticular nucleus. In addition to the above, a manic-
depressive sixty years of age, two general paretics, one sixty-eight,
the other sixty-five, and a woman seventy-six years of age who had
been continuously in hospital over forty years, were examined.
None of the cases in this group exhibited plaques. In the
arteriosclerotic woman dying from haemorrhage and in one of the
luetic cases (thirty-one years of age) with multiple gumma, large
fibre-forming glia cells and groups of macrophages laden with
lipoid stuff were encountered at the periphery of gummata in the
latter case, and about a small softening in the former case. These
cell colonies, however, were not the plaques with which we are
concerned in this paper.
IX. THE PLAQUES.
Methods Employed.—Bielschowsky's silver impregnation
method, Mann's eosin-methylene blue mixture, acid fuchsin-light
green, Mallory's phosphomolybdic haematoxylin—the three last as
employed by Alzheimer—Weigert’s glia and myeline sheath stain,
Mallory's glia stain, Scarlet after Herxheimer, van Gieson's stain
after alcohol and bichromatic fixation, Haidenhain's haematoxylin
and toluidin blue after alcohol and on frozen sections, were the .
technical methods employed in the microscopical examination of
the cases. The silver stain of Bielschowsky, Mann's stain, fuchsin-
light green, Weigert’s glia method—when successful—and scarlet
on fresh material, proved the most instructive for study of the
plaques. No case which failed to show plaques by Bielschowsky
method revealed these structures by the other methods employed.
Microscopic Appearance of Plaques.—The general morphology
of the plaques in silver impregnated sections and in sections stained
with Mann's solution is characteristic. The other methods ex-
hibit certain details with less uniformity. The plaques may be
described as discrete structures of variable size in which a dark,
circular, homogeneous, nuclear-like mass is centrally disposed.
Surrounding the dark, homogeneous portion is an area of variable
extent, always larger and lighter than the nuclear portion and
darker than the adjacent brain tissue. (Kern and Hof respec-
tively of Alzheimer'). In the outer portion of the plaque (court),
glia and nervous elements and other not definitely determined
58
structure —fibrils, granules and globules—are found. Under low
magnifications (Fig. I, 2, 3), even with the oil immersion (Fig. 4,
5, 6), the plaques are usually circular. Other shapes—square (Fig.
7, 8), triangular (Fig. 9) and irregular forms (Fig. I7)—are en-
countered. Certain reactions of the glia in and about the plaques
serve to differentiate what appear to be young forms from old ones.
The glia constituents and the elements of nervous origin which
one finds within the plaque exhibit not only progressive but re-
gressive changes, as well. The tinctorial nuances shown by the not
clearly determined substances of the outer portion indicate that
these may be of different chemical composition, probably stages
in elimination of the products of degenerated nervous structures.
While the homogeneous nuclear portion is usually roughly circular
in outline, higher magnifications reveal a jagged periphery which
frequently imparts the appearance of the many-pointed star of an
Official seal. This is usually well shown with Mann's stain and
Often in silver preparations and fuchsin-light green sections. A
well defined nuclear mass, by these methods, does not reveal any
cellular contents. Nevertheless, plaques, such as Fig 6, showed
occasionally a group of nuclei at the centre, in the position usually
occupied by the homogeneous mass. Between these nucle1 were
clear Spaces. Such microscopical pictures were interpreted as
encapsulating glia cells about a nuclear mass not in the plane of
the section. Plaques without a homogeneous nuclear-like mass
are not rare and for the same reason, as pointed out by Alzheimer.
An unquestionable attempt at glia encapsulation is often well
brought out even in Bielschowsky silver preparations. Alzheimer"
has published a convincing illustration of glia encapsulation of the
nucleus shown in a section stained after the Weigert method.
Fig. 6 is a photomicrograph of a plaque displayed in a silver im-
pregnated section from Case X. Large fibre-forming glia cells are
seen at the periphery sending fibrils which may be traced, on the
one hand, as far as the nuclear mass and on the other hand—in
at least one instance—to a nearby blood vessel. In the cases of
this series, the glia cells in and about the plaques, although show-
ing at times a rich fibrillosis, were more frequently of the type of
gliogenous phagocytic cells. (Gliogene Abraumgellen, Alzheimer,
Merzbacher et al). Gliogenous phagocytic cells in frozen sections
treated with Herxheimer's stain for lipoid substances, also with
Mann's stain and fuchsin-light green after Flemming's fixation, are
frequently met with. So-called amoeboid glia cells are also displayed
in frozen sections stained with Mallory's phosphomolybdic acid
haematoxylin. In two cases of the series (XII, XV) Herxheimer's
stain displayed a fine bright red stippling of the nuclear portion of
the plaque which was not encountered in any of the other cases.
59
A somewhat distinctive type of plaque (Fig. Io) is best shown
in silver impregnated sections. Here it will be seen, relatively
coarse, tortuous curled and club-shaped fibres dominate the pic-
ture. Other fine fibrils of about the calibre of neurofibrils, are en-
countered. These fine fibrils and by far the great majority of the
coarse fibrils were not stained by any of the methods which display
glia fibres. The fibres, as can be seen from the photomicrograph,
are disposed in a radiary manner. The whole plaque presents much
the appearance of the ray fungus of actinomycosis to which it has
been likened by several observers (Achúcarro” et al.). The whole
process, as shown in Fig. IO, presents many points in common
with regeneration of nervous elements in the cerebro-spinal axis
Such as is described by Bielschowsky, Pfeifer, Marinesco and
others. Methods which display axis cylinders reveal these fibrils,
although it must be admitted in a way which suggests that the
supposed axis cylinders are undergoing a degenerative process.
In Weigert myeline sheath preparations myelinated axis cylinders
are occasionally seen within the plaque.
If we turn to Figs. 5 and 9, Mann's solution and fuchsin-light
green stains respectively, many more or less discrete or confluent
globular masses are shown in the body of the plaque between which
clear spaces suggestive of channels are seen. Whether or not
these spaces are channels for the passage of fluid stuffs from the
nucleus to the periphery of the plaque, or in the opposite direction,
or whether they represent a purely artificial fissuring resulting
from the technic employed, is not clear. These fissures have
been found alike in sections cut free after fixation in Weigert’s
glia mordant and in most carefully embedded material after the
same fixative, subsequently stained with Mann's solution. The
plaques in sections treated with Mann’s solution, except where
glial and vascular elements obtrude, are stained blue, the nuclear
body a dark blue, the surrounding globules varying shades of a
lighter blue. The globules shown in Fig. 9, for the most part, are
stained in varying nuances of red; sometimes one or more globules
take on both the red and green elements of the stain and are then
a muddy blue color. A semblance of the original glia reticulum is
Cccasionally shown in fuchsin-light green specimens (Fig. 9) within
which these globules seem to lie. With both stains, as shown in
Figs. 6 and 9, discrete globules may be seen and larger masses
which appear to have been brought about by a coalescence of
smaller globules. Further, there are globules which appear to be
the result of thickening of trabeculae in the diffuse glia mesh.
Some plaques (Figs. 7, 8, IO) show a thickening of fibrils
about the periphery. Some of these fibres are evidently glia, as
shown by various stains, and others appear to be axis cylinders.
6O
But the great majority of plaques (Fig. 4) were without evidence
of thickening or proliferation of fibrils about their periphery.
Topographic and Stratigraphic Distribution of Plaques—Plaques
when present are usually widely distributed throughout
the cerebrum. Areas of predilection, independent of general
pathological alterations, are not the rule, at least not in this series.
Case IX, however, exhibited plaques only in the left prefrontal and
left hippocampal regions. The left prefrontal and left hippocam-
pal in this case had nothing in the way of general gross altera-
tions or even histopathological changes, save plaques, to distin-
guish them from the corresponding regions of the right side. But
in general it may be said, the frontal lobes and the hippo-
campal regions display the greatest richness in plaques. Pre-
cisely these are the regions which show generally the most ad-
vanced and most extensive histological lesions in the brains of
aged persons, whether dying insane or not. Cases IX, XIV, XV,
exhibited in TI and transverse gyri of Heschl, a richness of plaques
equal to that found in any prefrontal region of the entire series.
Here, however, their number is commensurate with the general
pathological lesions found in this area (see clinical analysis pp.
5OI-502). In general the occipital cortex shows the fewest plaques,
but one case (V) presented in the occipital cortex almost if not quite
as many plaques as were shown in its prefrontal regions. In this
Series, plaques have been found in the basal ganglia, white sub-
stance of the cerebrum and in the brain stem. In the cerebellum
no typical plaques were found, but in Cases XIII and XV in areas
of the molecular layer, dark and light staining, large as well as
Small corpora amylacea were seen in some foliae, missed in others.
Around these corpora there was occasionally a proliferation of
glia fibres such as seen about numerous corpora amylacea in the
hippocampal region of Case XXXI. No plaques have been found
in the spinal cord, although cords were not available for all the
cases. Finally, the portion of convolutions forming the lips of
sulci show more plaques as a rule than the Summit area.
As regards the stratigraphic distribution of plaques in the
cerebral cortex considerably variability was shown. No cortical
layer appears immune as a possible site for plaques. In a section
where plaques are not numerous they are most generally confined
to the layers of small and medium sized pyramidals. In other instan-
ces, especially where clinical Symptoms and general pathological
changes were severe, an unbroken array of plaques extending
from just beneath the pia, throughout all the cortical laminae, deep
into the white substance, could be demonstrated (Fig. 2). In
the hippocampal region, an area often equally rich as the frontal
for its content of plaques, the greatest involvement is usually
6I
found in the layer of large pyramidal cells, but numerous plaques
in all layers of this region are common (Fig. 3). Here, too, the
largest plaques are most generally found. (Compare Figs. 2 and 3,
which are photographs of the same magnification, one represent-
ing the prefrontal region, the other the hippocampal).
In the white substance of convolutions, plaques, when present,
are most numerous just beneath the cortex. Nevertheless, in the
very centre of the marrow stalk of many gyri a goodly number
have been frequently found.
Relation of Plaques to Glia and Nervous Elements and to the Vas-
cular Apparatus-The presence of glial elements in and about the
plaques has been noted by practically all observers who have
studied these miliary areas, but the interpretations of these glial
elements have varied. From the studies of Held,” Alzheimer" and
others, we have learned that the glia is more than a support struc-
ture for the mesoblastic and nobler epiblastic elements of the cen-
tral nervous system and a replacement tissue in case of destruc-
tion of nervous elements; that an important group of glia cells
do not proliferate fibres; that proliferated glia fibres are not neces-
Sarily emancipated, as was formerly supposed; that appreciable cel-
lular glial proliferation may take place in advance of demonstrable
alterations in the morphology of nervous elements; and that the
glia possesses Scavenger functions which, perhaps, are as impor-
tant as any other function of this many sided tissue. In and about
the plaques almost every known characteristic of the glia is demon-
Strable. While some of the glia phenomena may quite safely be
looked upon as secondary reactions to the plaques— as, for ex-
ample, attempts at encapsulation by means of a rich fibrilosis—
others are not so easily explained. Whether or not we can con-
sider the plaques as originally groups of glia cells—secondary to
Some stimulus and yet primary in so far as plaque morphology
is concerned—undergoing regressive changes into which nervous
elements proliferate and later degenerate, is not clear. In any
case, the problem as to the original stimulus which gave rise to the
primary glial proliferation, whether originating from nervous ele-
ments or inherent in the glia itself, must be faced, even though a
definite solution may not be reached.
Alzheimer" early maintained that certain glial proliferations
surrounding corpora amylacea and other bodies were identical
with the miliary sclerosis described by Redlich. Recently" he has
argued a similiar origin for plaques and amyloid bodies. But the
views concerning the origin of amyloid bodies differ, falling readily
into two classes: those which contend for an origin from regressive
alterations in nervous elements and those which assign their origin
to degenerated glia cells. As early as 1857 Rokitansky" main-
62
tained that these structures had their origin in regressive metamor-
phosis of myelin elements. Rindfleisch", in a series of observa-
tions, published in 1863, stated that some of the small uninuclear
cells between the fibres (presumably glia fibres) undergo an amyloid
degeneration and concluded that the familar corpora amylacea
had their origin in this manner. Fromman,” in 1867, also ad-
vocated a glial Origin.
Turning to more recent contributions which deal with the
Origin of amyloid bodies, we have on the one hand Ceci" (1881),
Schaffer“ (1890), Holschwenikoff" (1890), Siegert" (1892), Stroebe"
(1894), Catola and Achúcarro” (1906), Nager" (1906) and Wolf"
(1907), maintaining an origin from degenerating myelin sheaths,
axis cylinders, and products of degeneration of nervous elements
and the like. In short an origin from nervous elements. On the
other hand, Redlich" (1892), Obersteiner" (1900), Nambu" (1907)
and Hamilton” (1910), are convinced of the glial origin of corpora
amylacea. It has been pointed out that amyloid bodies are gen-
rally found within the meshes of the glia reticulum. Quite gen-
erally, when not encapsulated by actively proliferating fibre-form-
ing glia cells, amyloid bodies in the central nervous system are
Surrounded by a mass of glia fibres which, while variable in extent,
do not seem to be due to a crowding of the trabeculae of the diffuse
glia net but are apparently the result of a true fibrillosis. This is
especially well shown even in Nambu’s Fig. I. The fibrillary glia
wrapping about amyloid bodies, recorded in Case XXXI of this
series (p. 515), and the amyloid bodies in the molecular layer of
the cerebellar cortex of Cases XIII and XV with their surround-
ing glia elements, show much in the way of glia reactions that
are found in and about the plaques.
That actual proliferation of axis cylinders may take place in
the portion of the plaque peripheral to the nuclear-like body, is
demonstrated in many sections from the cases of this series. The
proliferated nervous elements do not appear to differ essentially
from the proliferation of axis cylinders in glioma, focal compres–
sion of spinal cord (Bielschowsky”), injuries (Pfeifer”) and experi-
mental lesions (Marinesco”, and Marinesco and Minea”). These
proliferations of axis cylinders the writer is inclined to consider
as ineffectual attempts at replacement.
With regard to plaques and ganglion cells, the examination of
the cases here reported furnishes no good reason for Supposing an
origin from degenerated ganglion cells. True, ganglion cells at the
periphery of plaques or even well within plaques are not rare find-
ings. The great majority of plaques, however, do not show any
especial affiliation with ganglion cells. It is also true that in not a
few instances where ganglion cells are seen at the periphery or
63
within the plaques such cells exhibit a fair state of preservation.
Perhaps the best argument which may be used against a ganglion
cell Origin is the frequent appearance of a great number of plaques
in the molecular layer and white substance of the cerebrum and
this too without the slightest evidence of a heterotropia of the
stratigraphy of ganglion cells.
Several observers have called attention to the not infrequent
proximity of plaques to small blood vessels and the similarity, it
not identity, of many granules found in plaques to granules found
in the walls of the vascular apparatus under conditions of active
destruction of nervous elements. In the sixteen cases exhibiting
plaques, while proximity to blood vessels was not rare—instances
of which may be seen in Figs. 7 and 8—the great majority of
plaques were distributed without any such reference.
Association of Plaques with Alzheimer’s Intracellular Degeneration
of Neurofibrils.-In the study here reported, the type of intracel-
lular degeneration of neurofibrils to which Alzheimer was the
first to call attention, has been found in some of the severe cases
of senile dementia, in Some comparatively mild cases, in the case of
precocious senile dementia (type of Alzheimer and Perusini) and
in the case of an elderly man dying without psychosis. The num-
ber of cells exhibiting this type of neurofibril degeneration was
variable, Some of the cases showing only a few such cells, while
in others, particularly in the frontal regions, by far the great
majority of cells were so affected. In some sections it was diffi-
cult to find a ganglion cell which did not show the alteration. The
Small and medium size pyramidal cells furnished the largest number
of examplars, next to these the cells of the fusiform layer. In
3 Cases (XII, XIII, XV), particularly in the frontal regions but
also in regions of marked atrophy, all of the cortical laminae were
affected to the same extent. In another group of three cases such
cells were found only in sections from the cornu Ammonis. Indi-
cation of this type of degeneration is also seen in sections treated
by other methods which do not ordinarily display neurofibrils. In
sections from corresponding areas treated after the Nisal method,
the evidence of marked cell degenerations is seen. (Fig. 16.) The
distribution and intensity of ganglion cells affected with Alzhei-
mer’s degeneration corresponds on the whole with the distribution
and intensity of general gross and histopathological lesions. Well
developed Alzheimer's degeneration of neurofibrils was found only
in brains showing plaques. One of the cases discussed under sec-
tion VIII, a manic-depressive fifty-five years of age, exhibited
many cells of the character shown in the drawing Fig. I2. Such
cells were also found in cases in which many cells exhibited a well
marked Alzheimer's degeneration and are interpreted as possibly
64
an early stage in the process which leads to the peculiar whorl-like
and Snarled arrangement in the typical late stage. Nothing quite
comparable was shown in the supplementary material, nor in the
brains of the seventeen elderly subjects dying insane but without
plaques. A translation of Alzheimer’s description of the order of
changes in the intracellular neurofibrils which lead up to the pecu-
liar alterations has been given above (p. 484), to which the writer
can add nothing essential. The photographs (Fig. II) of the extreme
manner in which some cells may be affected are more eloquent than
a verbal description. Nine of the plaque cases exhibited this type
of ganglion cell degeneration. N
Attention would also be called to certain alterations found in
ganglion cells, generally among the large pyramidals of Ammon's
horn, rarely in other portions of the cerebrum (frontal region),
which Simchowicz describes under the name of Argentophile
bodies. These structures are small, homogeneous masses, usually
circular and surrounded by clear spaces. The Argentophile bodies
are smaller than glia nuclei and more numerous in cells from
which neurofibrils seem to have disappeared. (Fig. I5). The im-
pression is won that, perhaps, here we have to deal with coagu-
lative residue of neurofibrils, in a certain sense a process compar-
able to that which leads to the formation of Alzheimer's degenera-
tion. Large Argentophile bodies, such as described by Alzheimer
in a case of circumscribed senile atrophy, were not found in this
series, not even in the case in which there were areas of marked
focal atrophy.
X. SENILE DEMENTIA.
Campbell" in 1894, although not the first to call attention to
certain characteristic changes in the ganglion cells in cases of sen-
ile dementia, wrote: “The most striking and constant change of
senile insanity, however, is pigmentary or fuscous degeneration,
which affects all nerve cells of any size; some large pyramidal cells
and ganglial cells of the paracentral cortex may be seen wherein
the change has advanced so far that the protoplasm is almost en-
tirely replaced by pigment.” Hodge", about the same time, in a
communication on senile changes of ganglion cells in man and the
honey-bee, while not insisting “that nerve tissue is of any more im-
portance in relation to physiological dying than any other tissue,”
contended that the ganglion cell changes found in senium are to be
interpreted as normal physiological changes, the counterpart of
which may be seen in the parenchymatous cells of other organs
undergoing involution. In so far as offering an explanaton for
the cerebral histology of senile dementia, Hodge's viewpoint, while
having won staunch adherents, has not received universal recogni-
tion. Robertson," Carrier,” Alzheimer," Frankhauser” and quite
65
recently Simchowicz', can see in the histological picture presented
by brains of persons dying from uncomplicated senile dementia
nothing but an intensification of the histophysiological alterations
of normal senium. Simerling,” Appledorn,” Fischer,” Léri” et al,
and in a certain sense Southard”, too, conceive special pathological
factors in addition to the normal alterations of senium, although
the conception of these pathological factors are not definitely for-
mulated.
In the earlier fatigue experiments of Hodge,” “* * * and the
more recent experiments conducted by Dolley"ganglion cell altera-
tions, comparable to changes encountered in ganglion cells of per-
sons dying of senile dementia, were produced in normal adult and
young animals. In the one case, these alterations may be looked
upon as the expression of cell exhaustion experimentally accom-
plished in short time; in the other, on account of their general
character, no less a process of cell exhaustion produced by factors
in operation over a long period. Whether the typical picture of the
ganglion cells in senile dementia, or, for that matter, the psychosis
itself is the result of chronic intoxication—a view to which Lériº
inclines—or whether these cell changes are representative simply
of a physiological apparatus worn out by long continued use, seem
of secondary importance; for very likely beyond these lie other fac-
tors more fundamental and of greater moment.
Southard” and Léri" have urged particularly that one must al-
ways distinguish the clinical and anatomical changes of senium
from changes which are only coincident with senium. This point
the writer believes is well taken; for all too frequent mental con-
ditions and anatomical findings which have little or nothing to do
with senile dementia are classed among the distinguishing features
of the psychosis.
The gross brain anatomy usually found associated with senile
dementia is too familiar to be recounted, but a word should be said
of the commonly associated atrophy and arteriosclerosis to which
great etiological significance has been generally ascribed. As in
the Danvers State Hospital cases recently reported by Southard,”
so in the thirty-three elderly subjects dying insane recorded in this
paper, not one was without macroscopic evidence of arteriosclerosis.
But the degree of associated atrophy was not always commensurate
with the degree of arteriosclerosis, nor even when reversely stated
was a definite relationship established. These findings, then, are
also consonant with those of McGaffin" in his recent study of the
Taunton State Hospital material.
To determine the existence or non-existence of atrophy from
the accepted normal average brain weights is far from satisfactory
for the reason of wide variations within the normal. The estima-
66
tion of atrophy from the macroscopic appearance of the brain is
also susceptible to error, for, as pointed out by Reichardt", von
Torok," Rosanoff and Wisemann,” and others, skull capacity must
be taken into consideration in deciding for or against the existence
of brain wasting. Until comparatively recently no attempts have
been made to estimate skull capacity in relation to brain weights,
and such methods as have been suggested are tentative at best.
Attention has been called (p. 488) to the existence in this series
of so-called normal-weight brains with manifest atrophy and gross
focal lesions. One brain below the accepted standard for normal
weight exhibited only a minimum of gross vascular change which
could have been attributed to arteriosclerosis (p. 490).
Southard" asks the very pertinent question: “Granting that
physiological brain atrophy occurs, how can we distinguish patho-
logical atrophy therefrom?” He then proceeds to answer: “First,
the loss in weight is more marked in the latter. Secondly, the on-
set of the process may be premature. Thirdly, the progress of the
atrophy, as distinguished by clinical observation, may be much
more rapid. Fourthly, a group of cases will show differential loss
in brain weight, whereas the other organs will maintain weight
better.” Southard does not contend against “general nutritive
conditions, in part arteriosclerotic in origin,” as etiological fac-
tors in Senile dementia, but argues that local vascular changes as
producers of atrophy have not been proven. He thinks that
“senile atrophic changes in general” are “similar to those unknown
conditions which underlie thymus atrophy or menopause changes.
One gathers from Bolton's” " researches that he conceives for
many forms of insanity an arrested development of certain cor-
tical layers which may explain in part the generally low brain
weights in persons dying insane. In Bolton's senile dementia cases,
however, there were reported instances in which brains weighed
well within the accepted normal range. In the series of cases here
reported much smaller to be sure than Bolton's (the latter's in-
cluded IOOO cases of various forms of insanity), “ the relationship
of the degree of wasting to the degree of dementia” was not al-
ways, or even commonly, “very exact.” Finally, concerning atro-
phy, attention would be called to the studies of Donaldson" who,
nevertheless, emphasizes the danger of applying conclusions drawn
from laboratory experiments on lower animals, where conditions
may be controlled, to man, where conditions are almost never con-
trollable. To quote Donaldson: “The brain, like other organs, has
much water in it. I have followed in the rat the change in the per-
centage of this water from birth to maturity. It diminishes by
approximately ten points and this diminution is very closely corre-
lated with age. At birth the water forms about 88 per cent. of the
67
brain, and at maturity, about 78 per cent. . . . For the per-
centage of water in the human brain, the data are meagre, but so
far as we can gather them, they correspond to those for the rat,
and when adjusted for the rapidity of growth, the curve for man
fits that for the rat. A very striking coincidence.”
Concerning the vascular changes, Friedmann” differentiates
the physiological vascular alterations of senium from the patho-
logical vascular alterations by atrophy of the muscular coats in
the former and proliferation of the connective tissue fibres in the
latter.
It would follow, at least in part, from the cited observations
and the observations recorded in this paper, that atrophy and ar-
teriosclerosis in senile dementia rather than being dependent the one
upon the other are often merely coincident, but it is conceivable
that the latter under certain conditions—disturbance of the nutri-
tive supply, etc.—may hasten or increase the former.
The microscopical findings in the brains of the thirty-three
elderly subjects of this series are on the whole sufficiently distinc-
tive to separate the cases into two chief groups, and this not alone
by the presence or absence of plaques, but by the sum of their histo-
logical alterations which show certain differences of a qualitative
character.
The histological changes of the sixteen plaque cases will be
briefly considered in the Order of pia, vascular, glial and ganglion
cell alterations: |
The pia in all of the plaque cases save one, Case II, exhibited
proliferative alterations, more marked in some of the cases than
in others, most pronounced over the frontal convexity, the upper
half of the central convexity, over the larger sulci-particularly the
Sylvian—and over the superior surface of the cerebellum. The
pial hyperplasia consists in a proliferation of its most external cells
(endothelial layer), a great increase in number and thickness of con-
nective tissue fibres and the fibroblasts which give rise to such
fibres. The fibroblasts frequently exhibit regressive alterations.
These proliferated elements of the pia produce a thickening of the
membrane of from four to eight, or even more times, the normal
thickness of this structure. Between the proliferated fibres large
heavily laden pigmented cells of the same general character as the
macrophages (Koernchen Zellen) of the cortex are found, their num-
ber usually proportionate to the number of such cells found in the
walls of the cortical vascular apparatus. The content of these
cells is shown, by suitable dyes, to be chiefly so-called lipoid sub-
stances. Extracellular lipoid granules are also encountered free
in the pial mesh. Here and there, in sections of the pia, lymphoid
cells are occasionally seen but never in great number, and in some
68
of the cases a few mast cells are observed. None of the cases ex-
hibited plasma cells. The “osteoid plates” described by Robertson.
are not rare findings, but these precursors of the commonly oc-
curing spinal Osteomata are, however, far less numerous in the
cerebral distribution of the membrane than in the spinal pia. The
biood vessels of the pia present much the same condition as will
be described for the vessels of the brain.
The vascular alterations are regressive as well as progressive,
On the whole, the former predominating. In alcohol fixed material
stained with toludin blue or with Nissl's methylene blue-soap
Solution, the endothelial cells of large and small vessels exhibit
frequently a darkly staining and rather elongated nucleus. More
frequently than not the protoplasm of endothelial cells is tinged,
exhibiting also lipoid granules. With Herxheimer's fat stain the
lipoid content of endothelial cells is well displayed. Swelling and
splitting of the elastica are frequently very pronounced in the
larger vessels. The cells of the muscularis generally show a rich
fatty content and markedly degenerated elements are common
among them. The adventitial cells are frequently proliferated, but
the most striking feature of these cells is their rich lipoid content.
Here, too, one finds frequently free lipoid granules and richly pig-
mented macrophages, such as described for pia. The connective
tissue fibres in some of the cases, usually in the older subjects,
were markedly proliferated, in small as well as in large vessels.
So marked was the fibrous proliferation of the vessel wall in such
instances that the process could worthily be designated as an
“arteriofibrosis.” (Fig. I4.) The arteriofibrosis was best displayed
in Bielschowsky silver impregnated sections and in sections treated
with Mann's eosin-methylene blue solution. These proliferated
fibres are arranged either in a thick annular manner or in a series
of spirals which give a latticed appearance. Three of the non-
plaque cases also presented a rather marked arterio-fibrosis, but
these were among the oldest subjects of the group which aside
from plaques had much in common, histologically, with the plaque
cases as a whole. Hyaline degeneration of the wall of Small vessels
is occasionally encountered but less frequently than in the seven
more typically arteriosclerotic cases of the non-plaque group.
Depending upon the degree of cortical disturbance and upon the
acute, subacute, or chronic character of these disturbances, great
numbers of heavily pigmented macrophages are seen in the ad-
ventitia and perivascular lymph Spaces. p
The glia changes are also progressive and regressive in charac-
ter, the former, perhaps, predominating. These changes affect
the cellular as well as the fibrillary glia. Colonies of small fibre-
forming glia cells and colonies of giant glia cells are encountered
69
in the cortex. The glia “keel” of the molecular layer is of greater
extent than normal and in many instances equal in extent to the
glia proliferation found in this region in cases of general paresis.
The calibre of the proliferated glia fibres, however, is more delicate
than the proliferated fibres of general paresis. Many of the glia
cells, not only those in the vicinity of degenerating ganglion cells,
show a rich pigment content of their protoplasm, fuscous stuff of
apparently the same character as that seen in ganglion cells. In
cells of the Spider type yellow pigment (toludin blue, stained red
with Herxheimer's scarlet stain) deposited in fine granules is often
Seen. Where a process is given off from such a cell to a nearby
blood vessel, the impression is imparted that in this manner a part
at least of the products of pathological metabolism find their way
to the blood stream for elimination. A noticeable feature of these
sixteen cases was the comparatively insignificant satellitosis.
Where ganglion cells are the most degenerated, as for example
those cells showing an advanced stage of the Alzheimer intracellu-
lar degeneration of neurofibrils, satellites are either entirely absent
or at most exhibit in their vicinity only a few such cells, and this
regardless of the cortical laminae in which such cells are found.
Aside from the types of glia cells already mentioned, amoeboid glia
cells (Alzheimer), gliogenous phagocytic cells and a few rod cells
(Stäbchen Zellen) of glial origin are encountered. e
The most striking characteristics of the ganglion cells are
atrophy, tortuous dendrites which in Nissl preparations may be
followed for a considerable distance from the cell, and marked
yellow pigmentation. The pigmentation is not confined to the base
of the cell but generally deposited throughout the cell and may be
followed in the apical dendrite as far as this process is visible. The
intense lipoid pigmentation is best seen in frozen sections stained
with scarlet after Herxheimer. Some of the cells are mere
shadows, some are encrusted, others present large vacuoles. In
addition to these chronic nerve cell changes acute changes are
Often superimposed. The neurofibril changes, on the whole, are
such as previously described by Bielschowsky and Brodmann,"
the writer” and others, nine of the cases exhibiting the Alzheimer
type of degeneration. While there is usually no marked disturb-
ance in cell lamination, as in general paresis, there are instances
of considerable diminution in the number of cells present. Where
Alzheimer degeneration is advanced indications of cell devastation,
although not en bloc, as in senile cortical erosions, are seen in cor-
responding Nissl preparations from the same regional areas.
Finally, the presence of plaques in greater or less number serves
as an additional microscopical feature to differentiate these cases.
In the non-plaque material from elderly subjects dying insane,
7o
as pointed out above, seven are clearly arteriosclerotic dementia on
their clinical side. These seven cases present wedge-shaped cor-
tical areas of destruction in which there is marked fibrillary glia
proliferation. In three of the cases, if one puts aside the focal
lesions, the remaining anatomical changes are not essentially dif-
ferent from the preceding group, save in the absence of plaques.
On the other hand, one of the plaque cases presents the general
histological lesions, including wedge-shaped areas of cortical de-
struction, as found in seven cases of this group. The plaque cases,
as a whole, present lesions more closely allied to senile dementia
and normal senile involution, the non-plaque cases, by and far,
lesions which are better classed as arteriosclerotic.
The general histological changes found in Case XXXIV, an
elderly subject without psychosis, are essentially the same as those
of the plaque cases, though of less intensity. The histological
changes in the remaining five subjects without psychosis were more
of the character of lesions found in the purely arteriosclerotic
Ca,SeS.
XI. SUMMARY AND CONCLUSIONs.
The central point of this study has been the miliary plaques
commonly found in the brains of persons dying at an advanced
age. Consideration, however, has been given many other factors
which might have a causative relationship, or at least serve as an
explanation for these peculiar structures. A reasonable number
of cases (eighty-nine) have been studied more or less systematically
and four other cases added to the supplementary group discussed
under section VIII brings the total to ninety-three. Some of the
findings lead to conclusions which may be stated with a degree of
positiveness almost axiomatic; others still await interpretation.
The results of this study may be summarized as follows:
(I) While 87.5 per cent of plaque cases exhibited atrophy
sufficiently marked to be detected with the unaided eye, other
cases with equally marked atrophy were without plaques. Cases
with brains weighing well within the range of accepted normal
weight have shown plaques on microscopical examination, while
Other brains coming under the same category have been negative.
(2). A large percentage, (62) of plaque brains exhibited gross
focal lesions resulting from arteriosclerosis and all showed more
or less advanced cerebral arteriosclerosis. But cerebral arterio-
Sclerosis was even more pronounced in non-plaque brains.
Arteriosclerosis per se, therefore, appears to have little, if any,
direct causative relationship to the formation of plaques.
(3) Brains exhibiting general histological evidence of senile
involution, whether from persons dying insane, or from persons
dying without psychosis, are the most likely to yield plaques.
/ 71
(4) Since plaques have been found in the brains of elderly
persons dying insane and in the brains of elderly persons dying
without psychosis, and also as recorded in the case of a young
tabetic without psychosis, these peculiar structures can not be con-
sidered as characteristic for any special form of mental disease, al-
though occurring with greater frequency in senile dementia than
in any other form of insanity.
(5) The Onset of senile involution varies in different persons
and this may explain the presence of plaques in the brains of some
elderly persons and their absence in others.
(6) From the evidence furnished by Case XV of this series
and the published cases of Alzheimer and Perusini, a precocious
senium is conceivable. By precocious senium, however, some-
thing more than an early cerebral arteriosclerosis is meant.
ſ (7) Plaques when present in a given subject are more numer-
ous in the portions of the brain which show the maximum of gen-
eral pathological alterations. Hence in senile dementia, the group
of cases which shows the most frequent and extensive involve-
ment, the frontal and hippocampal regions, as a rule, exhibit the
greatest number of plaques.
(8) The presence of plaques in the molecular layer of the
cortex and in the white substance, often in great numbers, leads
the writer to contend against an origin from degenerating
ganglion cells. The 'view of deposited products of pathological
metabolism resulting from degenerating nervous elements (fibrils)
is advocated. The glial and also the apparently incontrovertible
neural proliferations are interpreted as attempts at elimination
of the deposited products. These attempts at elimination and re-
placement, nevertheless, do not appear successful.
(9) The general histological evidence of these cases tends to
show a similarity between the lesions of senile dementia and
normal senile involution of the brain. The non-plaque cases of
the series more nearly approximated the histological lesions of
arteriosclerotic dementia. On the other hand certain non-plaque
cases which coursed clinically as senile dementia did not show
histologically, except by absence of plaques, lesions essentially
different from the plaque cases.
(IO) Uncomplicated senile dementia appears on histological
grounds, therefore, to be only an intensification of alterations
found in normal senium.
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Mºsco. Etudes sur le mécanisme de la régénérescence des fibres
des nerfs périphériques. Jour. f. Psychol. u. Neurol. Bd. 7, p. I40.
Marinesco et Minea: Nouvelles contributions à'l'étude de la régénér-
escence des fibres du systeme nerveux central. Jour. f. Psychol, u.
Neurol., Bd., 17, p. II6.
Campbell: The Morbid Changes in the Cerebro-Spinal Nervous System
of the Aged Insane. Jour. Ment. Science, Vol. 40, N. S. I35, p. 638.
74
57.
58.
59.
6I.
62.
63.
64.
65.
66.
67.
69.
7O.
7I.
72.
73.
74.
75.
76.
77.
78.
79.
Hodge: Changes in Ganglion Cells from Birth to Senile Death. Ob-
Servations on Man and Honey-Bee, Jour. Physiol., Vol. 17, p. 129.
Robertson: Text-Book of Mental Pathology. Edinburgh, 1900, p. 359.
Carrier: Etude critique sur quelques points de l'histologie normale et
pathologique de la cellule nerveuse. Thése de Lyon, 1903.
Frankhauser: Zur pathologischen Anatomie der Dementia senilis.
Monatsschr, f. , Psych, Bd. 25, p. 122.
Siemerling: Geistes-und Nervenkrankheiten. Lehrb. der Greisenkrank-
heiten v. Schwalbe.
Appledorn: Beitrag zur Kasuistik der Geistesstörungen im Greisenalter.
Inaug. Diss. Rostock 1908. Cited by Southard 64.
Léri: Le cervau Sénile. Résumé, Revue Neurol. Aug. 30, 1906.
Southard : Anatomical Findings in Senile Dementia: A Diagnostic
Study Bearing Especially on the Group of Cerebral Atrophies. Am.
Jour. Insan. Vol. 66, p. 673.
Hodge : Some Effects of Stimulating Ganglion Cells. Am. Jour.
Psychol. Vol. I, p. 479.
: Some Effects of Electrically Stimulating Ganglion Cells. Am.
Jour. Psychol. Vol. 2, p. 376. }
: The process of Recovery from the Fatigue Occasioned by the
Electrical Stimulation of Cells of the Spinal Ganglia. Am. Jour. Psy-
chol., Vol. 3, p. 530.
e Microscopical Study of Changes due to Functional Activity
in Nerve Cells. Jour. Morphol., Vol. 7, p. 95.
: Die Neverenzellen bie der Geburt und bein Tode an Alter-
schwäche. Anat. Anzeiger, Bd. 9, p. 706.
Dolley: Studies on the Recuperation of Nerve Cells after Functional
Activity from Youth to Senility. Jour. Med. Research, Vol. 24, p. 309.
McGaffin: An Anatomical Analysis of Seventy Cases of Senile Demen-
tia. Am. Jour. Insan., Vol. 66, p. 649.
Reichardt : Ueber die Untersuchung des gesunden und kranken
Gehirnes mittels der Wage. Jena, IQ06.
von Török: Ueber ein neueres Verfahren bei Schädelcapacitäts-Mes-
sungen. Virchow's Archiv, Bol. 189, p. 248.
Rosanoff and Wiseman: A New Method for the Estimation of Cranial
Capacity at Autopsy. Review Neurol and Psychiatry, Vol. 9, p. 54.
Bolten: Amentia and Dementia: A Clinico-pathological Study. Jour.
Ment. Science, Vol. 51, No. 213, p. 270, No. 2I4, p. 507, No. 215, p. 659;
Vol. 52, No. 216, p. I, No. 217, p. 22I, No. 218, p. 427, No. 219, p. 7II;
Vol. 53, No. 220, p. 84.
Bolten: The Histological Basis of Amentia and Dementia. Mott's
Archives of Neurol. Vol. 2, p. 424. -
Donaldson: President’s Address. Philadelphia Neurological Society.
Jour. Nerv. Ment. Disease. Vol. 38, p. 257.
Friedmann: Die Altersverånderungen und ihre Behandlung. Berlin u.
Wien, IQ02.
Bielschowsky u. Brodmann : Zur feineren Histologie und. Histopatho-
logie der Grosshirnrinde. Jour. f. Psychol, u. Neurol., Bd. 5, p. I73.
Fuller: A Study of the Neurofibrils in Dementia Paralytica, Dementia
Senilis, Chronic Alcoholism, Cerebral Lues and Microcephalic Idiocy.
Am. Jour. Insan., Vol. 63, p. 4I5.
EXPLANATION OF PLATES.
FIG. I.-Bielschowsky’s silver impregnation. Plaques in outer laminae
of paracentral cortex of Case I, , severe form of senile dementia (presbyo-
phrenia). Bausch & Lomb 2-3 achromat. Obj., no ocular, bellows extension I
m. 75 cm.
fiG, 2–Bielschowsky’s silver impregnation method. An unbroken array
of plaques extending throughout the cortex into the marrow. Prefrontal area, ,
left, of Case XV. Clinically and anatomically resembling cases described. by
Alzheimer and Perusini, designated in 8th. edition of Kraepelin's Clinical
75
Psychiatry as “Alzheimer's Disease.” Verick obj. No. O, no ocular, bellows
extension I m. 92.5 cm.
FIG._3–Bielschowsky's silver impregnation method. Ammon's horn of
Case XXXXIV, a man aged 80, dying without psychosis. Plaques in this region
are generally larger than found elsewhere. Compare with Fig. 2, both
figures taken under identical magnification.
FIG. 4.—Bielschowsky’s silver impregnation method. High magnification
of one of the plaques shown in Fig. I. A homogeneous nuclear-like body
is displayed surrounded by globules, between which there is a diffuse tinge-
ing, rod-like fragments—some straight, others slightly spiral. At periphery,
lower right, an intact ganglion cell. No appreciable thickening nor prolifer-
ation of axis cylinders. Zeiss 2 mm. apochromat obj., projection oc. No. 2,
bellows extension 80 cm.
FIG. 5–Mann's eosin-methylene blue stain. Frontal area of Case XIII,
“simple senile dementia.” The plaque exhibits a central dark homogeneous
mass with peripheral projections. Surrounding the nuclear-like mass irregularly
staining globules and glia cells are seen. (Alzheimer’s Kern and Hof re-
spectively.) In the portion of the plaque designated as the “court” fissures
suggestive of channels are seen. Whether these fissures are artefacts, or
whether channels for the elimination of degenerated stuffs is not determined
from this study. Zeiss 2 mm. apochromat obj., projection oc. No. 2.
G. 6.-Bielschowsky's silver impregnation method. Frontal area of
Case X, severe senile dementia complicated with advanced cerebral arterio-
Sclerosis. Moderately advanced attempt at glial encapsulation. Large fibre-
forming glia cells at periphery sending, on the one hand, fibrils which may be
traced as far as the central nuclear mass, and on the other hand, in one
instance at least, fibrils to a nearby blood vessel.
FIG. 7–Bielschowsky’s silver impregnation method. Large, more or less
square plaque from the innermost layer of left prefrontal region, Case V, a
woman 79 years of age, who had recovered with defect from a psychosis 27
years previous, suffered various severe illnesses during the first 40 years of
life and in the last illness presented clinically severe involution symptoms
which were also demonstrated anatomically. A dark homogeneous central
mass is shown surrounded by numerous fibrils many of which under sharp
focus are observed to stand in direct relation with glia cells. Below and to
right a blood vessel showing progressive-regressive changes. Zeiss 2 mm.
apochromat obj. projection oc. No. 2, bellows extension 90 cm.
FIG. 8–Bielschowsky’s silver impregnation method. More or less square
plaque from rt. cornu Ammonis, Case V. described in preceding legend.
In the region where the homogeneous dark staining mass is usually found,
there is shown in this photo. a colony of glia cells which is interpreted as
an encapsulating gliosis of a nuclear mass not within the plane of the section.
Globular masses, fibrils and peripheral fibrillary gliosis are also present, the
latter, however, not in good focus. The photograph was taken to show
mainly the central group of glia cells. Photographic details as in Fig. 7.
FIG. 9-Fuchsin-light green stain. Frontal area, right, Case I. The
plaque is roughly triangular in shape, presenting a nuclear-like mass near
its mid-portion, numerous globules which take the red element of the stain
in various nuances, numerous fuchsinophile granules, fragments of axis
cylinders and glia nuclei. Unfortunately the photograph does not do justice
to the various color reactions of the plaque, which are beautifully displayed
by this stain. Zeiss 2 mm. apochromat obj., no ocular, bellows extension I
II]. 22 CI11.
FIG. Io.—Bielschowsky’s silver impregnation method. Parietal area of
Case V described in legend for Fig. 7. The plaque is composed chiefly of
rather thick, curled and spiral fibrils which are not glial, but, for the most
part, proliferated axis cylinders. Many of these fibrils are undergoing re-
gressive changes. This type of plaque, while not rare, was less frequently
encountered in this study than the type of plaque shown in Fig. 4. Zeiss
2 mm. apochromat obj., projection oc. No. 2, bellows extension 95 cm.
FIG. II.-Bielschowsky’s silver impregnation method. Ganglion cells
exhibiting Alzheimer's type of intracellular neurofibril degeneration. De-
76
spite the marked alteration of the cellls there is no satellitosis. Indeed in
the neighborhood of some cells satellites are absent. Nine cases presented
this type of ganglion cell degeneration. In three cases they were found only
in the cornu Ammonis and one of these was an aged man dying without
psychosis. In general the frontal and hippocampal region show the greatest
number. Sometimes, in frontal lobes, all of the cortical laminae are effected.
Where such cells are few the small pyramidals present the greatest involve-
ment; next to these the cells of the fusiform layer. Some sections show scarcely
a cell in which there is no evidence of the change. All of the cells here
photographed were taken under the same magnification and represent different
cortical laminae. Zeiss 2 mm. apochromat obj., projection ocular No. 2.
Bellows extension I m. 50 cm.
FIG. I2–Bielschowsky’s silver impregnation method. Large pyramidal
cell of prefrontal cortex from a manic-depressive, 55 years of age. No plaques
found. The case was one of the supplementary material discussed under
section VIII. Many ganglion cells showed darkly staining, thick, tortuous
neurofibrils suggestive of possible early stage in Alzheimer’s degeneration.
No young subjects showed anything quite comparable. Similar cells were
also seen in cases which showed a well-advanced Alzheimer's degeneration.
Drawn with the aid of an Abbe camera lucida, Zeiss 2 mm. apochromat obj.,
compensating oc. No. 8. Reduced I-5.
FIG. I.3.−Fuchsin-light green stain. Blood vessel in the marrow of right
occipital lobe near the cortex and at periphery of recent focal softening,
Case XVII. Clinically a case of post apoplectic dementia; anatomically recent
focal softenings, pacchymeningitis haem, interna, marked hemiatrophy due to
ancient lesions of left basal ganglia and internal capsule. Numerous large
Abraumgellen free in marrow and cortex, singly and in colonies, some of which
have coalesced. Adventitia and perivascular lymph spaces crowded with
such cells. Coalescence of such cells have been described by Bickel as a
form of plaque, here interpreted as usual reaction to acute destruction of
nervous elements which may be found in any brain under like conditions.
Zeiss 8 mm. apochromat obj., projection oc. No. 4., bellows extension I m.
72.5 cm.
5. I4.—Bielschowsky’s silver impregnation method. Small vessel in
layer of small pyramidal cells paracentral cortex of Case V. Arteriofibrosis
described in the text. This type of vascular change was found in most of
the older plaque cases and also fairly common in the purely arteriosclerotic
cases of the non-plaque group of elderly subjects. Zeiss 2 mm. apochromat
obj., projection oc. No. 2, bellows extension 96 cm.
FIG. I5–Bielschowsky's silver impregnation method. Cornu Ammonis
of Case XVI. Large pyramidal cell exhibiting coarse dark granules sur-
rounded by clear spaces (Argentophile bodies). Such cells are common in
Ammon's horn but have been found also in the frontal areas. Usually where
found intracellular neurofibrils have for the most part disappeared. Zeiss
2 mm. apochromat obj., projection oc. No. 2, bellows extension I m. 27 cm.
FIG. 16.—Toluidin blue stain after Nissl Prefrontal area, left, Case XV.
To show the ganglion cell devastation in an area where plaques and Alz-
heimer's degeneration were well marked. Bausch and Lomb 2-3 achromatic
obj., no ocular, bellows extension I m.92.5 cm.
Fig. 17.—Mann's eosin-methylene blue stain. Paracentral cortex of Case
XIII. Irregularly shaped plaque showing, superiorly large glia cells and a
few small globular masses apparently within the glia mesh. Zeiss 2 mm.
apochromat obj., no ocular, bellows extension I m. 37.5 cm.
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IV
RECOVERIES IN DEMENTIA PRAECOX.
BY WILLIAM W. Coles, M.D.
Perhaps no problem of clinical psychiatry is exciting more
interest at the present time than that of the prognosis in dementia
praecox. Certainly no questions are more frequently put to the
physicians in our various hospitals by anxious relatives than
those relating to the outcome of this form of mental disease.
Affecting as it generally does the younger members of the family,
those in whom parental hopes are centered and who often
have, until a comparatively short time before the hospital ad-
mission, given much promise for the future, the anxiety to get
some definite statement, if possible one that may be encouraging,
is by no means incomprehensible. And still less so when the
course of these cases is considered, marked as it often is by what
appears to the family as a sudden onset due to some trivial in-
cident of daily life, to say nothing of the favorable progress which
frequently characterizes the earlier months of their hospital
residence.
Basing an opinion upon the statements of the earlier European
authorities as well as on observations made during the first years
subsequent to the recognition of this form of insanity in this coun-
try, the response to these inquiries has often been favorable. Fur-
ther experience, however, soon developed a conservative attitude
which led the physician to place at least a somewhat different in-
terpretation upon clinical features which are common to almost
all psychoses. “Possible recovery with defect” came to be the
standard formula with which these anxieties were met, while
in the minds of many psychiatrists the rapid deterioration
following periods of temporary improvement as well as the pro-
found disturbances characteristic of the more frankly unfavorable
types, overshadowed the picture and “once a dementia praecox
always a dementia praecox” came to be a commonly heard phrase
in the privacy of the office, if not in the reception room; but careful
students of psychiatry have not been willing to accept either the
relative optimism of the earlier view nor the epigrammatic pessi-
mism of the later, without statistical data, and the present paper is
offered as a contribution to this phase of the subject.
We have taken our material from a group of cases admitted to
the Westborough State Hospital during the years 1904, 1905 and
1906, believing that the intervening six to eight years should
give us a reasonable perspective for our observations, an oppor-
tunity to determine the validity of our opinion of the patient’s
78
condition at the time of discharge. Three hundred and two cases
Subsequently diagnosed as dementia praecox were admitted to
the Hospital during the above mentioned period, 182 women and
I2O men. Of this number 124, 75 women and 49 men, have been
constant residents here, have been transferred to some other
hospital in the State or are boarded out in private families under
direct observation of the State Board of Insanity. The course
of the psychosis in those resident in this institution has been
progressive, and the report concerning those transferred to other
State hospitals or boarded out is no more favorable. Thirty-two,
23 women and 9 men, died in this or another hospital. Thirty-
four, 16 women and 18 men, were deported either by the United
States Immigration Commission to their native countries or by the
State Board of Insanity to other States. None of these cases
were classed as recovered at the time of their discharge from the
hospital. Five men made good their escape from the institution
and under the names they bore here have not been admitted to
any other hospitals in the State; two of these having taken up their
residence, one in a Southern and another in a Western city, have
written letters to us which are part of our records and fit in well
with the psychosis as observed during their hospital confinement.
Seventy-two, 45 women and 27 men, were permitted to leave the
hospital in the care of friends but were not considered as recov-
ered at the time of their discharge and for this reason have been
eliminated from special consideration in the present paper. How-
ever, the writer is familiar with the subsequent history of a fair
percentage who have been able to remain at home but have shown
a degree of indifference or instability characteristic of the milder
cases of dementia praecox.
There remain, then, as the subjects for the present study 35
cases, 23 women and 12 men. Of this number one man was
accidentally drowned a few weeks after his discharge from the
hospital and his case can be eliminated. Another man having
had a previous admission to the hospital was removed as a
recovered case, but after a relatively short remission was recom-
mitted and has for the past three years shown marked indifference
and untidiness, features which were not observed to any extent
during his former hospital residence, though the diagnosis of
dementia praecox had not been questioned. Three cases, two
women and one man, were subsequently readmitted to the hospital
and again discharged recovered, the diagnosis in each having been
changed at the second admission to manic depressive insanity.
For obvious reasons those cases can be left out of our discussion.
An attempt has been made to obtain data as to the subsequent
79
histories of the remaining thirty cases. The difficulties are of
course apparent. Several of our letters of inquiry met with no
response whatever, owing probably to indifference on the part
of relatives or friends or even, possibly, to suspicion of the motive
prompting the inquiry, not unnatural among the ignorant. As
many more we were unable to reach owing to changes of residence.
We have been able to communicate directly with twelve cases, five
by personal interviews and seven by letter.
CASE I. No. 6023. Admitted June 1, 1904, age 21. Family
history negative, but both parents were of mixed white and negro
blood. Healthy until the present illness, free from any eccen-
tricities, a graduate at I7 of a city high School and since then
employed as a milliner. She has worked very hard in the shop
and done sewing for herself at home in the evening beside
studying music. Six months ago she suffered a nervous break-
down and had to give up her work, but had returned to it though
not entirely well, and her work worried her. The death of her
mother at this time she took greatly to heart. Menstruation had
ceased for three or four months. A week before admission she
suddenly developed the idea that she had committed some crime
and was to be arrested. She said that she had disgraced her
family, made repeated attempts to suicide and was excited, restless
and emotional. She masturbated excessively. After her admission
the excitement continued, resistiveness was a feature, and she made
attempts to suicide. Delusions with hallucinations persisted.
To relieve the apparent intense sexual excitement orificial works
was done, but there was no improvement until December 1904, when
she commenced to interest herself in her surroundings. She
improved slowly but made frequent complaints of pain in the left
Ovarian region. After careful consideration and surgical con-
Sultation a vaginal hysterectomy was performed, the left ovary
being found cystic and the tube inflamed. She made rapid prog-
ress after recovery from the operation, and November 27, 1905,
was discharged, showing good insight and her normal ambition
for work. Her brother reports that she has continued to improve
at home and gained in weight. For the past four years she has
been in business for herself as a milliner and dressmaker and has
done well.
CASE II. No. 6095. Admitted July 29, 1904, age 24, a
native of Austria, five years in the United States. Mother
insane for a year in middle life, but recovered. Maternal uncle died
of apoplexy. A tailor by trade, he has worked steadily all the time
since coming to this country, but changed his place of employment
three or four times. For the past two years, has worked very
8O
hard and in the same place. Became tired out and decided to take
a rest, in the early part of July going to a Y. M. C. A. camp in
northern New England. Remained there but one week, saying
that he could not rest because of the noise. Returned home and
gave expression to persecutory ideas and fantastic delusions deal-
ing with religion. He was irritable and confused.
When admitted he was not confused but excited, irritable and
Occupied with his persecutory delusions. He showed ideas
of reference. After a short period of improvement, during
which partial insight developed, he again became excited, and
these fluctuations in his conditions persisted for six months. At
times he was untidy and negativistic. During the middle of
January, 1905, he was interested in regular employment and made
a steady gain. He left the hospital for a trial visit March
I, Igoș, and renewed his furlough April 29, having worked steadily
at his trade and appearing in a normal condition. He was finally
discharged April 30, 1905. Following his discharge he worked
for nine months for his brother and has since been in business
for himself, doing well. *
CASE III. No. 6265. Admitted December 18, 1904, age
18. Hereditary tendency denied. Has always been a source
of anxiety to his family, could not learn in School and though a
fair worker was very unstable and often ran away from home.
He was very untruthful, and stole money from his family and em-
ployers. He was twice at the Lyman Reform School, and because
of excitement, violence and threats of suicide during his last
residence there was committed to Westborough.
When admitted he showed no defect of memory or orientation
and was not especially excited. He claimed that he heard voices
which threatened him with death. His range of thought was
limited and judgment very poor. After the first day he never
referred to hallucinations except on one occasion following a short
period of irritability, a frequent symptom if he was not allowed
his own way. He made his escape once from the hospital but
was returned after two months, during which he had worked a part
of the time. He claimed to be subject to what he called “fainting
fits, ’’ but they never manifested themselves during his hospital
residence. From February 1906 to the time of his discharge,
March 1, 1907, he was fairly stable but always showed the same
limited range of ideas and was dependent on others to a marked
degree, having some new request to make of the physician at every
opportunity. Certain facial mannerisms developed during this
period. He has visited the institution several times since his dis-
charge, and though he has managed to keep out of trouble and
8I
has worked more steadily than formerly he shows the same general
characteristics.
CASE IV. No. 6299. Admitted January 13, 1905, age 25.
Father alcoholic and a patient at Danvers before his death.
Many of the paternal grandmother's people were tubercular.
After passing the period of susceptibility to the children's dis-
eases he suffered from nasal catarrh and had an attack of typhoid
in 1900. Was always very self-conscious and inclined to keep by
himself. He gradually grew a little deaf, and for two years com-
plained of ringing in his ears. He graduated from the Massachu-
setts Institute of Technology in 1901, in the department of
Electrical Engineering, and has been employed in the West in the
practice of his profession. For a year he has not had his usual am-
bition for work and has seemed dull and indifferent, as shown by
his letters from the West as well as in his attitude after coming
home in November 1904. At that time he was depressed, talked of
himself as a failure and was suicidal; was at a private Sanatarium
for a short time before coming to Westborough.
When admitted was much depressed and very nervous,
constantly sniffling and biting his nails. Talked of his life as a
failure and of his hopeless future. Orientation and grasp on his
surroundings were good and he had partial insight. No hallucina-
tions. A period of marked apathy with mutism and untidiness
supervened immediately following admission and he tried to escape
from the ward. In the latter part of February frank cataleptic
manifestations with cerea flexibilitas developed, persisting until
the middle of May with marked loss in weight. At that time he
again began to talk, showed evidence of active hallucinations of
hearing and threatened suicide persistently. During the summer
and fall he showed a little improvement, but in December 1905 he
passed into a state of acute excitement, was very noisy and in-
coherent, talking in a silly manner and showing marked restless-
ness. He was utterly careless as to his appearance. During IQO7
the excitement gradually subsided and he became very apathetic,
though hallucinations persisted. In November of that year he
passed through an attack of acute rheumatism, during which
there commenced a definite improvement in his mental state. On
January 28, 1908, he gave a detailed account of the experiences
of his psychosis and the delusions to which he had given expres–
Sion, showing good insight. He could recall nothing of the
cataleptic period. He was anxious to leave the hospital but was
willing to leave the matter to the discretion of the physicians.
His subsequent recovery was uneventful, and June 19, 1908, he
was discharged. His mother states that he has been well since
82
and worked regularly at his profession in spite of the fact that
his illness meant some loss of Standing among certain of his
associates. He has had an attack of appendicitis without the
development of the least mental abnormality. To quote his
mother: “He has fully recovered mental balance. He seems to
have suddenly emerged from boyhood to manhood, with a keen
sense of all of a man's responsibilities.”
CASE V. No. 6442. Admitted May 5, 1905, age 34. Father
intemperate. Patient of a nervous temperament, two choreic
attacks in childhood, an attack of la grippe in 1898 which
left her very weak physically for a year. Latter part of March
present year a second attack of la grippe lasting two weeks. She
then commenced to develop vague fears of impending calamity.
She went to visit a friend, and soon got the idea that the friend
was holding her a prisoner for some purpose. At this time she
admitted that she was not in her right mind, said that she could
not think. On admission she was well oriented and had some
insight, but repeated her delusions and said that recent experiences
were very much mixed in her mind. She was very quiet. Three
days later she became excited, restless and gave evidence of hallu-
cinations of hearing. This condition persisted during the summer
and was followed in the early autumn by a period of dulness, nega-
tivism and a tendency to be unsocial. There was no retardation.
In November she commenced to gain in weight with corresponding
mental improvement which persisted until her discharge March 18,
1906, at which time she had full insight and a normally ambitious
attitude toward the future. She has since been constantly em-
ployed as a typesetter and seems normal in every way.
CASE VI. No. 6608. Admitted October 18, 1905, age 33.
Heredity denied. Always well as a child and has been a
healthy woman. Married two years, and August 27 gave birth
to her first child. Two weeks later, while apparently making
a good recovery from the puerperium, a child belonging to one of
her sisters died. This upset her very much and she became much
depressed, refusing to have anything to do with her own baby. She
then became excited and talked incoherently. When admitted she
was depressed, confused and seemingly negativistic. She refused
to answer many questions. In October and November she took
no interest in her surroundings and was constantly tube-fed. Early
in December she commenced to improve and by the end of the
month was able to give an account of her actions and ideas, admit-
ting that she had been insane. The subsequent recovery was com-
plete and she was discharged January 31, 1906. Her husband states
that she has been perfectly normal since and has given birth to a
second child without any accompanying mental symptoms.
83
CASE VII. No. 6777. Admitted January II, 1906, as a
transfer from the Northampton State Hospital, age 22. Maternal
aunt a patient here. Aside from the usual diseases of child-
hood she was well. Married at I6, her first baby came a year
later, and two months afterward she became maniacal but was
treated at home; has been unstable since. Her husband left her
three years ago, since when she has supported herself by doing
housework, working in many different families in as many dif-
ferent towns. She was picked up on the street in Springfield, Au-
gust 30, 1905, acting in a manner indicating excitement and con-
fusion. At Northampton she continued in this state during her
entire residence, was hallucinated and had poorly defined persecu-
tory ideas. When admitted to Westborough she was quiet and
gave an account of her life corresponding with the known facts,
but insisted that her experience at Northampton was part of a
scheme of persecution. She continued quiet during her hospital
residence, but never seemed indifferent and developed very good
insight into her condition. She gained 25 pounds in weight.
April 2, 1906, she was discharged. She immediately obtained
employment in the Dennison factory at South Framingham, where
she continues to work. She has been well physically, is interested
in her work but has been under close supervision of her mother,
and becomes very irritable if she gets overtired. The mother does
not consider that she is entirely normal mentally.
CASE VIII. No. 6852. Admitted March 13, 1906, age
2O. Mother and maternal grandfather tubercular. Patient
never very well as a child and is described as being very nervous.
Whenever ill he was delirious. He was ambitious and a bright
student, graduating from high school at 18 and later taking a year
at Worcester Academy. In September 1905 he entered a technical
school in California, having gone West for that purpose. He
became very homesick and returned home December 12, but con-
tinued depressed and seemed confused at times. He worked in
two or three different places, however, during the winter and in-
sisted that he felt very well. Early in March he commenced to
show excitement and gave expression to grandiose ideas concern-
ing his wealth and ability as a financier. March 8 he was taken to
the Boston State Hospital as an emergency case and while there
was excited and destructive. When admitted to Westborough he
was excited and irritable, talking in an incoherent manner of his
grandiose ideas and giving evidence of hallucinations. He
was distinctly undeveloped physically and showed various stigmata
of degeneration. He made no improvement until the latter part
of April, when he commenced to quiet down and showed some in-
84
sight. May 8 he was given a limited parole, and a week later went
home without leave, being returned by his father the next day.
He subsequently continued to improve and was stable, insight be-
coming complete. He was discharged June 5, his father being
advised to give him employment on the farm with freedom from
responsibility. He has followed out this advice, and has had no
physical illness and is still doing well, taking great interest in his
work but not capable of carrying it on without paternal super-
V1S1O11.
CASE IX. No. 6917. Amitted May II, 1906, age 23. Father
died at age of 29 of tuberculosis. Patient had always been
well and was a good student, graduating from high school
at 16 and a year later from business college. Naturally of a
mild, even disposition. Her brother's death October 1, 1905,
caused her great depression, and in March 1906 she resigned her
position, as she was not in good physical condition and suffered
from insomnia. The latter part of that month she was very un-
stable, alternately singing at the top of her voice, playing the piano
very loudly or crying in a hysterical manner without provocation.
She talked of wanting to die and at other times of getting married.
Kept busy writing much of the time and said she was writing a play.
Under treatment at home she seemed to be improving, but three
days prior to her commitment she became much excited and
restless.
At the time of admission she was much excited, hallu-
cinated, confused as to her surroundings and without insight. She
talked incoherently in a playful and affected manner but gave ex-
pression to no definite delusions. Many of her remarks referred
to a certain gentleman friend. In July she showed marked nega-
tivism, and deep pin pricks in her body caused no reaction whatever.
Hallucinations of both sight and hearing were very active, continu-
ing so until the middle of October, when she became very
destructive, obscene in her talk and untidy in her habits. She
sang a great deal in a loud rasping monotone. For a short time
cerea flexibilitas could be demonstrated and facial mannerisms
were prominent. The latter part of that month she improved
very rapidly, all the symptoms disappeared except certain of the
mannerisms, and she developed good insight with complete recol-
lection of all the experiences of her psychosis. She was dis-
charged December 7, 1906, has worked regularly as a stenographer
and typewriter since January 1907, receives $50.00 per month
salary with good prospect of advancement.
CASE X. No. 6973. Admitted June 7, 1906, age 27.
Father, brother and a paternal uncle intemperate, the latter at
85
one time a patient at the Worcester State Hospital. Patient a nor-
mal child with average aptitude for study. Married at I9 and has
one child 3 I-2 years of age. Following an attack of la grippe
in March, 1906, which was marked by severe headaches, she
was confined to the house for several weeks with “muscular
rheumatism.” She brooded over her incapacity and became de-
pressed, often crying without apparent cause. She slept poorly,
and early in May developed the idea that someone was going to
burn her child. At times she refused to talk. June 5 she took a
solution of bichloride of mercury with suicidal intent.
On admission she was restless, confused, negativistic and often
assumed stereotyped attitudes. Within a day or two she became
mute. She did not present evidence of hallucinations. This
condition persisted until the latter part of July, when she com-
menced to show improvement in her mental state as well as in
weight. November 24, as her condition had progressed favorably
and she had good insight, she was permitted to go out for a visit.
She returned to the hospital January 21, 1907, to renew her fur-
lough and showed continued improvement, being finally discharged
the following day. She has had no return of mental symptoms
and has held her weight in spite of the fact that she does her
house work and is also in business for herself as a milliner.
CASE XI. No. 6990. Admitted June 27, 1906, age 17.
Father died of tuberculosis, aged 46. Paternal aunt a patient
at Worcester for three years but made a good recovery. A ma-
ternal uncle alcoholic. As a child the patient was nervous and
Suffered from nocturnal enuresis, but in boyhood he was much
better and did well at school. Three months ago he began to
lose interest in his studies, devoted much time to athletics and be-
came greatly discouraged because he was unable to make the
school baseball team. About this he talked a great deal.
He was very restless, suffered from insomnia, and ate very little.
June 26 he developed the idea that a crowd of people were follow-
ing him. The next day he wandered aimlessly about the city until
brought home by force and then refused to eat or drink, became
mute and was destructive.
On admission he was quiet, refused to answer most questions,
would not do anything for himself and at times resisted passive
motion. He made a great many purposeless movements with
his hands and showed evidence of hallucinations of sight, hearing
and touch. Within three days following admission he became
acutely excited as a result of the hallucinations, and continued
so with short periods of remission until September. He was
noisy, irritable, incoherent, restless, destructive and masturbated
t 86
excessively, the hallucinations often dealing with sexual subjects.
Early in September he commenced to improve, developed complete
insight and was stable. October 29 he went home on a visit, re-
turning December 26 and being finally discharged the following
day as he was in good condition. He has been interviewed fre-
quently by the writer since his discharge and has not shown any
abnormality. His mother writes that he has been constantly em-
ployed in the city forestry department and has never given
evidence of a return of his mental trouble.
CASE XII. No. 7075. Admitted August 19, 1906. Heredity
marked, and general course of the case characteristic of
dementia praecox, hebephrenic form. During the summer of 1907
she improved, showing good insight and an active interest in her
surroundings and home affairs. August 22 she went out for a
visit which did her good, returning September 7, and September 18
she was discharged recovered. April 15, 1908, she again returned
to the hospital, her condition at that time showing progress in the
course of her psychosis but no marked changes. She remained
here until June 20, 1910, when she was discharged as not im-
proved to enter a private institution. At present her relatives
are caring for her at home, but her mental state is that of a case
of hebephrenia in its more advanced stages.
Analysis of these twelve histories shows five cases—IV,VII,
VIII, IX, and XII—which seem to belong in the dementia praecox
group. Case IV with the prolonged catalepsy, the outbreaks of
excitement and a long period of indifference, in spite of the final
development of complete insight and a return of a normal mental
activity, appears typical of the katatonic form. Case VII, present-
ing a long period of instability followed by an outbreak of excite-
ment marked by hallucinosis and vague persecutory ideas, may be
classed as a hebephrenic with the reservation that there is a defi-
nite basis of constitutional inferiority and that the recovery, while
sufficient to permit her to gain her livelihood, cannot be considered
complete. Case VIII, likewise showing certain physical evidences
of an inferior individual, the instability and characteristic excite-
ment, we would also consider as a hebephrenic who has recovered
with defect. Case IX would hardly be placed in any other than
the hebephrenic group in spite of the absence of the usual dementia
praecox characteristics from the period prior to the development
of the psychosis, and there certainly seems to be no evidence of
defect at the present time. Case XII offers no difficulty what-
soever, but we must revise our opinion as to recovery at the first
admission considering the apparently normal state then reported
as but the commencement of what proved to be a relatively short
remission.
87
As to the other seven cases there is in our own mind consider-
able question as to the diagnosis. Case I, while presenting delu-
sions having a strong sexual coloring with active hallucinations
of hearing, emotional instability and seeming negativism at cer-
tain stages, offers definite prodromata entirely compatible with
those observed prior to a manic depressive attack, while the
general clinical picture is not different from the so-called mixed
cases of that group. There is no reservation as regard the recov-
ery here. Case II must be classed as doubtful. There seems to
have been a certain dementia praecox makeup in the patient evi-
denced in the reported instability quite pronounced during the in-
terval between his arrival in this country and the commencement
of the psychosis, but the difficulties which a foreigner meets during
his early residence in a strange land are not to be lost sight Of,
and here again we have a definite cause for mental breakdown in
the period of overwork reported in the anamnesis. The hospital
history can be interpreted either as that of a case of hebephrenia or
manic depressive insanity, but it seems to us that considering the
short durations of symptoms suggesting hebephrenia we are safe in
classing our patient in the latter group. Case V can be classed
in the same way with less question, interpreting the period of dul-
ness following the excitement as one of the reactions not infre-
quently observed in manic depressive insanity. Perhaps an ex-
haustion-infection psychosis cannot be entirely eliminated from
consideration, but the confusion noted was not of sufficient
intensity nor was her general physical condition compatible with
such a diagnosis. Cases VI and X, however, seem to us frankly
of this type, the apparent negativism being but an evidence of con-
fusion of marked intensity and the relatively short hospital
residence in both with coincident physical and mental improvement
pointing strongly in this direction. Case XI offers some doubt,
but the absence of a frank pre-psychotic dementia praecox trend,
the fairly well defined cause and the course of his psychosis certain-
ly makes manic depressive insanity the more probable diagnosis.
Case III, while offering many symptoms characteristic of hebe-
phrenia, for short periods during his hospital residence, cannot be
kept out of that class of imbeciles of fairly high grade whose
Separation from the dementia praecox group is at times a matter
of considerable difficulty. Here the subsequent history is of
assistance and helps to place the case.
It will be seen from the above analysis that while the estimate
of the condition of the patient at the time of discharge may be
valid in the great majority of cases, the diagnosis may well be sub-
ject to revision, and a Superficial review of the other histories in
88
Our group of recovered case as well as in the total admissions
for the three year period will not be out of place. Eighteen cases
who were discharged recovered have received no special considera-
tion for reasons noted above. Of this number five presented un-
questioned evidence of dementia praecox, and in the case of three
of these the statement of the condition at the time of discharge
was later qualified as recovery with some defect. In four cases
difficulties of diagnosis present themselves and make any definite
classification impossible without further history either of the pre-
hospital stage or that subsequent to discharge. Five can be
placed in the manic depressive group without any question,
certain symptoms having been given more than their true relative
importance in first classing them as dementia praecox. Like-
wise two cases of late onset can better be considered as examples
of that form of depression occurring during the period of involution
and may also be placed in the manic depressive group if we are
going to eliminate from our classification the term “involution
melancholia.” In the case of one of these the term “recovery with
defect” was used with reference to her condition on discharge.
Both are interesting because of their presentation of certain char-
acteristic dementia praecox symptoms in psychoses occurring during
the fourth decade of life. We do not deny them place in the de-
mentia praecox group because of their age, for other cases occurring
at that time of life have come under our observation, but the entire
absence of the pre-psychotic instability or eccentricity which is
always a factor in these cases of delayed onset determines us
against such a diagnosis, while in each a strong tendency through-
out life to periods of melancholy on insufficient provocation points
strongly to the manic depressive makeup. Of the two remaining
cases one diagnosed as the paranoid form of dementia praecox and
presenting a prolonged course with well defined paranoid ideas not
well systematized, with recovery at the time of discharge, may be
classed with the group of cases best characterized as paranoid
conditions. Her subsequent history bears this out, and there has
been no evidence of dementia. She was able to conceal her delu-
sions at the time of discharge, and we do not feel that her case
can be properly considered in the recovered group but was pur-
posely left there because deserving of special reference. The other
was diagnosed as katatonia and made a rapid recovery, but careful
study shows that the period of mutism and lack of interest which
characterized the case was in reality a prolonged confusion and
the etiological factors brought out are entirely compatible with
those to be found in the exhaustion-infection psychoses.
Eliminating these 35 recoveries there remain 267 cases in
89
which a diagnosis of dementia praecox was made during the three
year period. In our general review of these it has appeared that
27 can be placed in a group by themselves either as extremely
doubtful or frankly to be classed as examples of other psychoses,
basing such an opinion on the evidence of their hospital history
subsequent to the making of the diagnosis. The number is not
large nor are the errors at all remarkable when the multiform
character of the dementia praecox complex is taken into considera-
tion. A detailed reference to them would not add to the present
discussion, but that such errors occur calls attention to the fact that
more or less frequent revision of our diagnosis in this and other
psychoses would give greater accuracy and add to our knowledge
of psychiatry.
A glance at the above analysis will show that in but one
or two cases has the post-psychotic period been considered, and
in all the condition of the patient at the time of discharge has been
taken as a criterion. We have approached the subject without per-
mitting any preconceived opinion to play a part in the estimate of
the results. To say that because a given case recovers it cannot
belong in the praecox group seems unscientific, at least in the pres-
ent state of our knowledge. Had we the same definite etiological
and pathological factors to deal with as have been established
for general paresis such an affirmation would be justified. But
two of the cases, VII and VIII, of so-called recovery cannot be
admitted because of a defect, apparent though not preventing
the patient from gaining a livelihood, and in one, Case XII, it has
already been shown to be but the commencement of a relatively
short remission. The absence of the characteristic dementia
praecox makeup, whether from the pre-psychotic or post-psychotic
lives of the other two cases, IV and IX, is a factor of no small im–
portance, leading us to be very skeptical as to the advisibility of
offering them as examples of true recovery from dementia praecox.
That the diagnosis plays by far the most important part in
an estimate of the prognosis has been the one outstanding feature
of this discussion. It has the same place in the papers of Mitchell
and Stearns of the Danvers (Mass.) State Hospital, and Hoch and
Whitney” of the Worcester (Mass.) State Hospital, read before the
meeting of The New England Society of Psychiatry of September
28, 191 I, both of which, dealing with groups of cases similar to that
of the present paper, offer reasons for affirming corresponding
errors of diagnosis among the group of recovered cases. Hans
Schmid of Lausanne in an exhaustive study of the subject bases
his estimate of the unfavorable prognosis upon the same con-
sideration. He calls special attention to the frequency with which
90
the confusional states are mistaken for katatonic manifestations, a
factor which has already been referred to in connection with three
of our cases. Furthermore, in the interests of more accurate
statistical data as to the condition of our patients at the time of
discharge, Schmid insists on the necessity of as careful a study
of the mental state at that period as at the time of admission,
whereby the possibility of diagnostic errors would be greatly
diminished. This, seems to us in the light of the present study
a point of no mean importance. Other European authorities,
Klipstein, Bleuler" and Kraeplin," are entirely in accord with the
views of the authors already mentioned, the latter stating his posi-
tion as follows: “The contention that dementia praecox is curable in
a scientific sense I hold to be hasty”, while Bleuler puts the matter
even more forcibly when he says, “There is no cure in the sense of
restitutio ad integrum.’”
Therefore, basing an opinion on the results of our study of
this series of commitments we should be extremely conservative
in offering a favorable prognosis in dementia praecox. That a
fair percentage of the cases may be discharged to their friends and
for a considerable length of time be able under proper environ-
ment to occupy a useful place in Society we would not for a
moment dispute.
REFERENCES.
H. W. Mitchell and A. W. Stearns. Remarks on the Prognosis of
Dementia Praecox., N. E. Soc. Psychiatry, Semi-annual meeting Sep-
tember 28, 1911. Am. Jour. Insanity, Vol. lxviii, p. 716 (Abstract).
Theo. A. Hoch and Ray L. Whitney. Recoveries in Dementia Praecox,
N. E. Soc. Psychiatry, Semi-annual meeting September 28, 1911. Am.
Jour. Insanity Vol. 1xviii, p. 718 (Abstract).
3. H. Schmid. Ergebnisse personlich erhobener Katamnesen bei geheilten
Dementia-Praecox-Kranken. Zietschr. f. d’gesamte Neurol, u. Psych.
Bd. 6, p. 125-I95, IQII.
4. Klipstein. Uber die hebephrenem Formen der Dementia Praecox. Allgem.
Zeitschr. f. Psych. Bd. 63, p. 512, 1906.
5 E. Bleuler. Endzustande der Dementia praecox (und diskussion). Allgem.
Zeitschr. f. Psych. Bd. 65, p. 436, 1908.
6. E. Kraepelin. Lehrbuch der Psychiatrie. I und 2 Band, 8 te. Auflage
I909–IO.
I
2.
V
THE SELECTION OF STIMULUs worDS FOR EXPERIMENTS
IN CHANCE WORD REACTION.
By ELEANOR A. McG. GAMBLE, PH.D., AND ALBERTA S. B. GUIBORD, M.D.
This paper aims at contributing certain data to the technique of
psychoanalysis by the association method of chance word reaction.
The name here adopted for the method is the name given by
Professor G. E. Müller; the method meant is the method ex-
ploited by Jung. The writers are taking for granted that the
reader is somewhat familiar with the theory and practice of psy-
choanalysis, but their own method of procedure is described in
detail below.” The conclusions here reported are the first glean-
ings from a mass of experimental results obtained in part at the
Westborough State Hospital, in part in the Psychology Labo-
ratory of Wellesley College, and in part in the South End of
Boston.** More than half the experiments have been made
and practically all the numerical work has been done in the last two
months. When time permits, the results may be worked over from
several different points of view, and even from the point of view
taken in this paper they may be tabulated in several different ways.
Here they have been submitted to rough-and-ready treatment in
order that the writers might have the honor of contributing some-
thing to this collection of studies.
Every one who has tried out the method of chance word
reaction knows that association times depend largely on the nature
of the stimulus words, quite apart from the individuality and the
history of the reagent. The purpose of this paper is not to show
up this obvious fact but to point out the factors in the word stimu-
lus which tend to make the reaction time long or short. The
phrase, word Stimulus, is used advisedly instead of stimulus word.
This work is not a study of individual English words in the attempt
to formulate a list thoroughly suitable for association experiments.
It is rather a study of the associative behavior of certain groups of
words. The words actually on the list are regarded simply as
specimens of classes. Wells enumerates in order of their impor-
tance, four factors upon which the quickness of reaction depends in
experiments of the sort under discussion. These factors are
(1) “the tendency of the associations to be presented in linguistic
form or in imagery readily resolvable thereto; (2) the relative pre-
*See Freud, The Origin and Development of Psychoanalysis, Amer. Journ. Psych.
XXI., 191o, 181-218; Jung, The Association Method, Ibid. 219-269; and Putnam, On
Freud’s Psycho-Analytic Method and Its Evolution, Boston Med. and Surg. Journ. CLXVI.,
I9 I2, IIS-I 22.
For our own method of procedure, see p. 555.
*June and July, 1912.
92
dominance of some single association; (3) the willingness or un-
willingness, from any cause, to utter the response word that pre-
Sents itself; (4) such direct inhibitory effect upon all voluntary
response as may be induced by any strongly emotional reaction
to the stimulus words,” The work here reported centres about the
nature of the stimulus word as likely to bring these factors and
perhaps still others of minor importance into play. The study
differs from earlier work, first, in the principles upon which the
list of stimulus words has been made up, and, second, in the selec-
tion of four different classes of subjects.
The subjects included (I) six members of the Wellesley
College Faculty; (2) twelve Wellesley students; (3) thirteen
patients at the Westborough State Hospital, all women; and (4)
six women who are free from any nervous disease but who are
relatively uneducated. These classes of subjects will be called
for brevity the instructors, the students, the patients, and the un-
educated. The writers began the study by comparing the reactions
of the insane with those of the sane as represented by the very
available college undergraduate. This comparison seemed un-
satisfactory because the students were much younger than most
of the patients and far surpassed most of them in formal educa-
tion. For this reason two other classes of normal subjects were
added: (1) a number of formally educated women who more nearly
resembled the patients in age, and (2) a number of women who
more nearly resembled the patients in education.
The term uneducated as applied to the fourth class of subjects
is, of course, an exaggeration. No one of the six is illiterate, and
Cases II, III, and V are women of quick understanding and fair
intelligence. Cases I, IV and VI, however, are decidedly ignorant.
Only Case II has “gone beyond the grammar school”, and even
this subject had only one year of high school work. Case IV is a
widowed seamstress, perhaps forty years old ; Case I is a vigorous
housemaid of about twenty; Case VI is an ailing and idle girl of
sixteen, the daughter of an intelligent restaurant waitress. Cases
II, III, and V are all young married women; the eldest, Case V,
must still be in her early thirties. Exact questions as to age could
not well be asked of these subjects. It is clear that the “unedu-
cated” subjects fall into a brighter half and a duller half. The reac-
tions of Cases II, III, and V are scarely to be distinguished, either
in matter or in time, from those of the college girls. Cases I and
VI, on the other hand, dealt in explanatory definitions (Case VI, in
childish use-definitions) and Case IV persisted in seeking terms op-
posite to the stimulus words and was direfully slow in reacting.
*Wells, Some Properties of Free Association Times, Psych. Review, XVIII., 1911, 2-3.
93
The writers would gladly have extended the list of uneducated sub-
jects, for experiments upon them proved highly instructive.
Such persons, however, are extremely hard to secure. Subjects to
whom English was not virtually the mother tongue were ruled
out and many of the persons approached refused to cooperate (or
to continue to cooperate) either as a favor or for pay. The recal-
citrants evidently regarded the experiments as a species of the
ever-to-be-detested school examination or as calculated in Some
mysterious way to get them into trouble. The very simplicity of
the procedure made the proposal of the experimenters the more
suspicious. Two of the subjects were finally secured through the
kindness of the Emanuel Memorial House and two through the
courtesy of Dennison House. Only in seeking these subjects did
the writers meet with rebuffs. The patients and instructors se-
lected were very willing and the college girls more than willing to
Serve.
In passing from the uneducated to the patients it should be
noted that all of the latter exhibited more intelligence and better
training than was shown by the more ignorant half of the former.
In fact, Cases III, VI, VII, IX, X, and XII among the patients
had all received more formal education than had any of the so-
called uneducated subjects. No one of the patients had passed col-
lege entrance examinations, but Cases VI and VII showed a com-
mand of the English language and a range of reading much greater
than the ordinary college girl can boast. Seven of the patients were,
however, very fairly comparable with the brighter half of the un-
educated subjects. The details in regard to the patients are as
follows: Case I is an unmarried woman of thirty, depressed and
perhaps suicidal. She has a very bad heredity as regards insanity
and is morbidly conscious of this fact but has no marked delu-
sions. Her reactions closely resemble those of the college stu-
dents. Case II is a married woman of forty-three, much de-
pressed. She believes that she has committed the unpardonable
sin and talks freely about the matter. Her reaction times are ir-
regular and rather long. Case III is unmarried and has held a
commercial position. Her age is thirty-four. She is probably a
case of dementia praecox and possibly has mental repressions.
Her history bears out both these suppositions and her reaction
times bear out the second. A peculiar feature of her reactions is
the frequency with which she named particular things and in-
stances, as, e. g., Sofa—our couch at home, pride—a certain man.
Case IV is a married woman of thirty-three. The diagnosis is
doubtful as between manic-depressive insanity (elated phase) and
dementia praecox, but her reactions point toward the latter. She
showed more instances of perseveration than any other subject
ever encountered by either writer. Often her reactions could be
94
interpreted only by going back several numbers on the list of stim-
ulus words. Often, also, her reaction was a word casually spoken
by one experimenter to the other. It is to be noted that when the
stimulus word was unpleasant, she nearly always gave the proper
reaction for an earlier word. She also tended toward assonance
associations and toward coining opposites to the stimulus words.
Roughness—ruffles, Roosevelt—rose, and weep—unweeped, are
characteristic reactions. Case V is a discouraged, neuraesthenic
woman of fifty-one, unmarried. She has held a responsible com-
mercial position and has carried heavy domestic burdens. She re-
acted with the same kind of labored explanatory definitions given
by Case I of the uneducated subjects, and her reaction times were
long. Case VI is a very intelligent unmarried woman of thirty-
four, who has also held a responsible commercial position. She
seems to be an hysterical case and lays claim to amnesias of the
closely circumscribed variety. Case VII is an unmarried woman of
thirty-three who has been a stenographer. She is a typical case
of dementia praecox and shows the pitiful wreck of an excellent
mind. Her reactions were nearly all definitions, but though frag-
mentary and marked by verbigeration in the repeated use of the
words lovely, and dainty, they nevertheless hit the nail very ex-
actly on the head. Specimens are sparrow—a lovely, commonplace
bird that goes in packs; star—comet, or on the stage, one that takes
a heavy part and is dainty; garret (taken for gorrote)—torture;
and Roosevelt—noisy man. She usually continued to explain each
stimulus word in lower and lower mutterings until the next word
was given. Her reaction times were not long as compared with
those of most of the patients. Case VIII is an unmarried woman
of forty, likewise a stenographer. She exhibits a mild case of de-
lusional insanity but is somewhat retarded and is easily fatigued.
Case IX is thirty-five years old, is unmarried and has been a
teacher. She is another clear case of dementia praecox and has
religious delusions, not distressing but apocalyptic. Case X is a
delinquent girl of twenty-four, difficult to manage even under hos-
pital conditions and expert care. The diagnosis is uncertain as
between dementia praecox and feeble-mindedness, yet her reactions
are more rapid than those of any other patient on the list and could
not be distinguished from those of the college students. Case XI is
an unmarried woman of forty-eight. Her diagnosis is uncertain,
but the most marked feature in her case is auditory hallucination.
During the first experiments, which were made upon her last De-
cember, she rhymed incessantly and often senselessly, as, e. g.,
puppy—luppy, lobster—clobster. In June, however, when the ex-
periments were finished, she rhymed very rarely and was much more
composed in behavior, although she still complained of hearing the
95
accusatory “voices.” Case XII is an intelligent well-to-do married
woman of fifty-three, a typical case of manic-depressive insanity
with remissions. Just now she is mildly exhilarated but shows
some insight. Her reaction times exhibit the curious retardation
which marks her psychosis even in its manic phase. Subject XIII
is a married woman of twenty-eight and is a typical case of in-
cipient dementia praecox.
The patients obviously make up a very heterogeneous group
of subjects. However, their variations in the matter of reaction
times from the standard set by the eighteen Wellesley subjects
are not such as to cancel one another. Those who differ from
this standard at all differ in the directions of retardation and
irregularity; and Cases I and X, who do not diverge, serve only
to lessen the gross difference in reaction time between the
massed results of the patients and the massed results of the
students and of the instructors.
Of the six instructors, whose ages range between fifty-eight and
twenty-nine years, Cases I, IV, and V belong to the objective type of
subject, the subject who reacts rapidly and mechanically without
being stalled or side-tracked, by misplaced introspection and with-
out taking the experiment as a kind of personal and perhaps
inquisitorial conversation with the experimenter. In Wells'
phraseology, these three reacted freely. On the other hand, Cases
II, III, and VI belong to the subjective type. Case II was much
too introspective. At the first sitting, she tended to react with
assonance associations. Case III showed more instances of per-
severation than did any other of the thirty-seven subjects except
Case IV of the patients. Case VI showed some symptoms of a
mental repression.
The students form a very homogeneous group and require
little comment. One was a senior; the others were all juniors
or sophomores; all were under twenty-four. Nearly all were of
the objective type. It is interesting to note that of two who are
particularly able and intelligent, one is very distinctly of the objec-
tive and the other of the subjective type.
The crux of this paper is the list of stimulus words. It seems
desirable to proceed directly from the statement and discussion
of this list to the discussion of the numerical results. The details
in regard to the experimental procedure will, therefore, be inter-
polated at this point. The points which it is proper to mention
are (1) the directions given to the subject, (2) the extent to which
defective reactions were counted, and (3) the methods of timing
the reaction.
(1) The subject was told to answer to each word pronounced
by the experimenter with the very first word which came into her
96.
head. She was not told to answer as quickly as possible. If she
complained that she often “thought of” or “saw” one or more ob-
jects before she could think of a word, she was told not to worry
about these visual “pictures” but to concern herself only with re-
porting the first word. The more intelligent subjects were told
repeatedly that only honesty was required of them, not speed,
and, much less, reactions of an interesting character. It was ex-
plained that a large number of remarkable reactions might simply
be a proof that they were not doing as they were told but were
“showing off”. The less intelligent subjects were told even
oftener that no “answer” was either “right” or “wrong”, that one
person would think of one thing first, and another, another. If
they reacted with definitions, they were told several times over
that they need not tell what the stimulus words meant, but as a
matter of fact, with a single exception, no subject who once
began to define could ever be stopped in this way. The untrained
or dull mind seems to maintain a kind of groping attitude when
the series of disconnected words is given, and admonitions are
useless. For each subject the nature of the performance desired
was, of course, illustrated before the experiments were begun.
(2) Reactions in the form of sentences, definitions containing
Several words and so on are, of course, contrary to the rules of
the game, but if all such reactions were thrown out, the results
from the less intelligent subjects would be meagre indeed. De-
finitions and assertions containing several words were, therefore,
included if the experimenter thought that the interval between
the giving of the stimulus word and the beginning of the reaction
had been properly timed. Questions were, however, thrown out.
In the case of the duller subjects, the experimenter tried to guard
against taking an inquiring or meditative repetition of the stimu-
lus word for the reaction proper. Often, however, the watch was
stopped upon this repetition. The time obtained when this mis-
take was made should always have been thrown out. In some few
cases, however, it was not, and this error tends to shorten the
apparent reaction time of the duller subjects.
(3) In the experiments on the patients and the uneducated,
the times were kept with a stop-watch reading to fifths of a
second. One experimenter started the watch as she pronounced
the stimulus-word, stopped it when the subject reacted and read off
the time to the other experimenter, who did all the recording neces-
sary. In the experiments on the students and the instructors, the
time was kept with a vernier chronoscope. One experimenter
pronounced the stimulus words and recorded the reactions and re-
marks, but not the times, which were not mentioned in the subjects’
hearing. A second experimenter released the long pendulum of
97
the chronoscope on the stimulus word and the short pendulum on
the reaction word, and counted and recorded the pendulum
swings, afterwards computing the seconds from the Swings. The
procedures with the stop-watch and with the chronoscope are
alike rough, but disregarding the inevitable errors, the time,
which can only be read at most to tenths of a second with the
watch, can be determined to fiftieths with the chronoscope. The
great disadvantage in using the chronoscope is that it consumes
time. After each reaction there is a halt while the pendulums are
coming into the same phase, and this halt may be just as long if
the subject reacts quickly as if he reacted slowly. A given set of
experiments takes nearly three times as long if the chronoscope be
used. For this reason, the watch was used with the patients and
with the uneducated, with whom it was necessary to proceed quickly
and whose variations were relatively gross.” The experiments on
the uneducated, and most of those on the patients were made by the
writers together. All the other experiments were made either with
the participation or under the very close oversight of one of the
writers.
The principles on which the list of stimulus words was made up
can best be explained to the reader after he has looked through
the list itself, noting the interpolations in italics. Before giving the
list, it is necessary only to say that half the words were designed
to serve as a standard from which each of the other words should
differ only in one or two respects. These standard words were not
Supposed to have in any marked degree any of the factors which
are known to lengthen reaction time. When half the words were
set up as a standard, it was proposed to find averages (with each
set of subjects) for all the normal nouns, the normal adjectives
and the normal verbs and to consider the time for the other nouns,
adjectives and verbs as exceeding or falling short of these nor-
mal averages. In view of the actual results, however, this pro-
cedure was abandoned. The reaction times for the normal words
differ so much among themselves that averages obtained from
them would be meaningless. Thus the standard words simply
*In comparing the two procedures, it became clear that the error in such experiments
would certainly be less if the person who pronounced the stimulus words were not the per-
son who started and stopped the watch as is usually the case. In the first place, the ex-
perimenter starts the watch as he gives the word and not as the subject apprehends it,
whereas an assistant will start the watch when he himself apprehends the word, and if
both he and the subject are intelligent persons with good hearing, their apprehnsion times
will be very nearly equal. In the second place, if one is supposed both to pronounce a word
and make a thumb or finger movement at the same instant, the shifting of attention is
likely to produce irregularities in the time relations of the two acts. Of course, in psycho-
analysis proper, it is undesirable to have an assistant present, and small errors in the
times matter, little. Nevertheless, times taken in the ordinary way—as in our experiments
with the patients and the uneducated—will appear a little longer and a little more irreg.
ular than if they were taken with the chronoscope as we used it. This fact is, of course,
not sufficient to account for gross time differences, such as appear between the patients and
the normal subjects.
98
serve as a kind of background or framework for the others in a
fashion which will be clear later.
A CLASSIFIED LIST OF THE STIMULUS WORDS.
STANDARD NOUNS, all general terms of not more than two syllables,
all likely to suggest stereotyped visual images, none very unpleasant and none
practically equivocal in meaning.
Parts of landscape:-river, star, cloud, rainbow, meadow, grass.
Parts of house:—porch, pantry, garret, kitchen, key-hole, cellar.
Parts of body:-wrist, knee, neck, ankle, tooth, flesh.
Articles of clothing:-ribbon, glove, jewel, shirt, bonnet, apron.
Textiles:–muslin, flannel, silk, wool, linen, velvet. .
h ºices of household equipment:-needle, sofa, clock, broom, kettle,
atchet.
Eatables:–lard, pudding, biscuit, mutton, salad, cookie; turnip, coffee,
wine, custard, ginger, cherry; syrup, grape, cheese, fig, melon, gravy.
Animals:–goat, puppy, pig, Squirrel, donkey, lion; whale, goose, panther,
tiger, kitten, eel; robin, lobster, parrot, sparrow, eagle, pigeon. .
Plants or parts of plants:—barley, ivy, moss, fern, clover, acorn.
Occupations:—farmer, plumber, priest, baker, grocer, druggist.
Poetical characters:—angel, gypsy, fairy, ogre, ghost, demon.
STANDARD ADJECTIVES, all expressing visible qualities but like the
standard nouns not abstract, unpleasant nor equivocal in meaning:—black,
white, grey, red, blue, green; yellow, grown, pink, purple, crimson, scarlet;
speckled, crooked, short, ragged, large, Small; ugly, pretty, blooming, bril-
liant, foaming, flaming; fiery, dainty, narrow, neat, wide, lurid.
STANDARD VERBs, all expressing visible actions or states but other-
wise like normal nouns:–Quench, pierce, spin, carve, glisten, flutter; shake,
fry, kindle, skim, eat, browse; prance, flit, fade, creep, cringe, shriek; bathe,
spill, weep, hang, swipe, wipe; trouble, flinch, shut, chew, build, gather.
WORDS FOR COMPARISON.
Words likely to suggest unpleasant concrete (non-verbal) images but
not likely to evoke any very strong emotional reaction:–blood, mucus, filth,
slime, reptile, worm; vile, greasy, nasty, dirty, bleary, putrid; wriggle, writhe,
drool, curdle, fester, reek.
Words likely to evoke unpleasant concrete images and also some indig-
nant surprise and embarrassment in reacting:—stink, pus, slobber, bloat,
vomit, urine. y
Nouns equivocal in meaning (when heard):—tail, game, eye, poker, cur-
rant, Soul.
Words equivocal in grammatical function—as often nouns as verbs:–
whip, blossom, grin, gleam, lurch, frown. (See also the sets beginning with
splash and with envy below.) e
Words equivocal both in meaning and in grammatical function:—altar,
medal, patient, bear, cross, tip. -
Words abstract in the sense of not, tending strongly to suggest some
particular non-verbal image:—hatred, pride, grief, joy, terror, malice; envy,
anger, shame, dread, love, disgust; virtue, fame, courage, future, beauty,
truth; perplexity, ambition, intemperance, impudence, discouragement, dis-
appointment; wicked, boastful, cautious, clever, silly, prudent; anxious, stupid,
noble, crazy, morbid, jealous; covet, punish, obey, amuse, pretend, deceive;
think, try, learn, forget, forgive, pity. -
Words likely to suggest concrete images other than visual:—colic, head-
ache, fever, roughness, voice, uproar; Splash, whistle, shriek, tinkle, howl,
whisper; sour, bitter, sweet, moist, hot, soft; slippery, fragrant, loud, spicy,
heavy, rapid; mutter, patter, tickle, Swear, freeze, crunch; beg, melt, speak,
bellow, twist, scramble. * tº
Nouns which differ from the standard nouns only in length:—molasses,
chrysanthemum, geranium, rhinoceros, potato, radiator.
99
General terms likely to suggest subordinates:—fruit, fish, insect, bird,
city, disease.
Proper names:—Taft, Lincoln, Moses, Bryan, Roosevelt, King George
(counted as one word).
Postcritical words, coming directly after the words supposed to be “shock-
ing”:—tulip, daisy, poppy, pansy, lily, holly.
The reader's first impression from this list will be that it is
very long, and if he reads it carefully his second impression will
be that it contains an extraordinary number of stupid mistakes.
For example, vile and browse, when pronounced are both equiv-
ocal in meaning, and the auditory images which swear evokes are
verbal and not concrete. These errors, however, are of no real
importance since, in the end, the results were not averaged in
groups. The list is given here in its uncorrected form in order
to indicate the composition of the shorter lists which were made
from it at the outset before anyone had observed the very obvious
errors. The complete list was divided into six short lists of fifty
words- each. These lists were closely parallel. It will be noted
that on the complete list the words are arranged in groups of
six or multiples of six. The first word in every six appeared on
the first short list; the second on the second short list and so on.
On the short lists the words did not appear in the order in which
they stand on the long list, but in an order determined by writing
them on separate cards and drawing the cards from the shuffled
pack. The classification of the standard nouns was simply a de-
vice for making the short lists parallel, and has no particular im-
portance.
To the students the six short lists were given at six different
sittings, but to the instructors and the patients it was necessary
to give two lists, and to four of the uneducated subjects all six lists
at a sitting. -
The characteristics of the stimulus words which the experi-
menters wished particularly to test are indicated on the list just
given, but may now be enumerated with some comment.
(I) Tendency to call up unpleasant concrete imagery, especially
visual imagery. May not such imagery so rivet the subject's atten-
tion as to hold back the verbal associate even though the subject may
not have the slightest objection to uttering the first word which
comes into his head? If one is given the word blood, may not the
horrid image, say, of a stuck pig, make one for the moment really
wordless and delay the utterance of the innocuous word red by
perhaps a second? For the present purpose the words which
tended to call up disagreeable pictures without shocking the sub-
ject are more important than the words which tempted her to with-
hold her really first reaction word. Every one knows what hap-
pens when a word is given to a subject to which for any reason he or
IOO
she fears to react. The “shocking” words on our list were put in to
Secure for purposes of comparison some instances in which our
normal subjects would really hesitate to react candidly. These
words, the set beginning with stink, may not seem to the medical
reader very shocking, but with our subjects there can be no pos-
sible doubt that they had the looked-for effect.
(2) Equivocal meaning. If a word tends to initiate two or
more series of associations, may not the two tendencies inhibit or
partially inhibit one another? If one is given the word guilt, may
not one react more slowly with the word sin because one has a
fleeting image of a gilded object and tends also to react with
'yellow or silver? May not this inhibition take place even if the
tendency to react, say, with yellow be not in any way represented
in consciousness? Certainly the reciprocal inhibition of associa-
tions is a fact of brain physiology unmistakably demonstrated by
the experimental study of memory.
(3) Abstract nature. If a word has no strong tendency to call
up a definite and particular concrete or other visual image, does
Or does it not, in virtue of this abstract character, tend to have a
long reaction time? Does the quick-coming visual image, which
in most persons will antedate any verbal associate with such words
as kitten or cheese, actually retard or facilitate the verbal reaction?
If one spoke of piety as often as of pie, might not one react to
piety more quickly than to pie?
(4) Tendency to evoke concrete imagery other than visual. The
question of the relative suggestiveness of color words and of sound,
taste and touch words, possesses a mild interest; but the point is
of very minor importance, both because concrete imagery which
is not visual, is relatively rare as compared with visual imagery, and
because, even when it does occur with any degree of distinctness,
it is commonly accompanied by visual imagery.
(5) Length. This is a point of considerable importance. If ex-
periments are made in the ordinary way and if the experimenter
starts the stop-watch as he begins to utter a long word, the reac-
tion time, as registered by the watch, will certainly appear longer
than if the word were short.
(6) Grammatical value or function. Do nouns, adjectives and
verbs tend in the 10ng run to exhibit differences of reaction time?
One might well expect an affirmative answer to this question,
since all kinds of linguistic connections and relations may be sup-
posed to influence verbal reaction time. f
These six questions are the only points of any importance
which were taken into consideration in making up the list of stimu-
lus words. The experimenters assumed that if a word is very
commonly coupled with another word in ordinary speech, its time
IOI
will be short; this fact is amply demonstrated in the results, but
was not a controlling factor in the formation of the list. From the
results also emerge at least three other characteristics in the
stimulus word which may have an effect upon the reaction time.
Before the numerical results are discussed it is necessary to
interpolate two explanations in regard to the way in which they
have been treated. On the one hand, when the average time for
a given word with a given set of subjects is spoken of, the arith-
metical average is meant. The median would scarcely represent
the facts. But on the other hand, reaction times for different
words have in no case been averaged together. For each class of
subjects separately, the average times for the different words
were written out in order from the least to the greatest, and the
median value of the whole series, the median of each half and the
median of each quartile were found. A word is said to lie in the
first octile when its reaction time is shorter than the value upon
which the line between the first and second Octiles falls. For ex-
ample, with the instructors, five words have a reaction time of I.28
seconds and thirty-five words have a shorter time. The line be-
tween the first and second octiles falls, therefore, on the time I.28",
since this is the thirty-eighth of the three hundred times on the
scale, counting from the shortest, The word molasses is then said
to belong to the first octile because with these subjects it had an
average reaction time of I.23".
A word or two should be said in passing upon the relative
quickness in reacting of the four different classes of subjects, al-
though this is not a point with which this study is greatly con-
cerned. The median value for the students is I.53"; for the instruc-
tors it is 1.545"; for the insane, 2.58"; and for the uneducated,
I.945". For the students the line between the first and second
octiles falls at I.30"; for the instructors, at I.28"; for the patients,
at 2. II"; for the uneducated, at 1.5o". The line between the
seventh and eighth octiles falls for the students at 1.99"; for the
instructors at 1.97"; for the patients at 3.50"; and for the unedu-
cated, at 2.77". Evidently the students and instructors are about
equally quick; and although the uneducated fall between the insane
and the normal educated subjects, they stand rather nearer to the
latter than to the former. From scrutiny of the results for indi-
vidual subjects it would appear that the retardation of the pa-
tients as compared with the students is really due to mental
disease and neither to age nor very largely to lack of education.
The retardation exhibited in the averages of the patients is due
to two causes, namely, to the genuine retardation of the manic-
depressive and the deteriorated subjects, and to the emotional dis-
turbances which many of the words produced even in patients who
IO2
can Scarcely be said to have mental repressions. For instance, Case
II was long (nineteen full seconds) in reacting to fiery. Her reac-
tion word was indignation. She thinks that she has committed
the unpardonable sin. (See Hebrews IO :26, 27.) As a matter of
fact, nearly all the patients were of the subjective type of subject,
not in the sense that they were particularly introspective, but in the
Sense that they took the stimulus words personally.
The numerical results may now be discussed in their bearing
upon the six questions which are primarily at issue and which con-
trolled the selection of the stimulus words.
(I) A stimulus word which tends to suggest unpleasant visual
imagery tends to have a high reaction time, even if it is not likely
to produce a true emotional reaction, but this effect is incon-
stant in comparison with the effect of words which do produce
emotion. For purposes of comparison the results for the shock-
ing words will be stated first. As one might expect, the students
and instructors were most perturbed by these words. All stand
at least as high as the sixth octile. With the students, stink, bloat,
vomit, and urine are all in the eighth, and urine has the fourth
highest reaction time of all the words on the list (3"). With the
instructors, pus, vomit and urine are in the eighth octile, and
wrine has a higher reaction time than any other word (3.18"). With
the patients, vomit is only in the second octile, but all the other
words stand at least as high as the sixth, and stink and slobber are in
the eighth. Only five words on the list show longer times than
these two words. The uneducated subjects were not phased by
stink or urine, which stand near the centre of the scale, but all the
other words stand in the seventh or eighth octiles. Turning now
to the words which have unpleasant associates but are not likely to
produce indignant surprise or embarrassment in reacting, one finds
that blood, slime, vile (which is also equivocal in meaning), greasy,
bleary, putrid, wriggle, writhe, drool and reek all have a well-
marked effect, but putrid and writhe are the only words of the whole
eighteen which are high for all classes of subjects, and writhe
stands high probably because it is hard to apprehend by ear.
With the students, only blood, reptile, vile, greasy, putrid, wriggle,
writhe, drool, fester and reek stand as high as the sixth octile, and
only vile, putrid, wriggle, writhe, drool, fester and reek are in the
eighth. Mucus, to which the college subjects almost invariably reacted
with membrane, is on the line between the first and second octiles,
and curdle, to which every one reacted with milk, never with blood,
is in the first. With the instructors, eleven of the eighteen words
under discussion stand as high as the Sixth Octile. With the pa-
tients also the number is eleven, but with the uneducated only
eight. With the different classes of subjects the make-up of the
IO3
lists of disturbing words is curiously different, and in many cases
one can see exactly why a word should fail to disturb subjects of
a certain class. Drool stood in the highest octile except for the
uneducated, where it stood on the line between the first and sec-
ond octiles. Three of these subjects are mothers of small chil-
dren. Mucus, on the other hand, stood in the highest Octile for
the uneducated who did not react with membrane. With the in-
structors, only nine words on the list have a shorter time than
blood, which with the other subjects stands in the sixth or seventh
octile. The instructors all reacted with red, with the exception of
one who said serum. On the whole, the results show that a
moderately high reaction time has no particular significance if
the stimulus word is likely to make a subject of a given class
image something rather nasty. Nevertheless, an inspection of the
results for individuals shows that retardations of this sort are
really very different from the delays due to radical disturbances in
the individual’s emotional life. Delays of this second sort
not only may occur in the case of words to which most sub-
jects react promptly, but they are also much longer than the
pause of trifling disgust or annoyance. The latter rarely ex-
ceeds by more than a full second the subject's median reaction
time, unless there is embarrassment in reacting, and even then it
rarely adds more than two seconds. On the other hand, the pause
when the morbid emotion of a patient, hidden or otherwise, is
tapped, has often, in our own experiments, lasted nearly twenty
seconds, even when the subject finally reacted. The writers are
the more anxious to record this impression because one of them
has entered even into the outskirts of psychoanalysis in a highly
skeptical frame of mind.
(2) Equivocal meaning in the stimulus word does not appear to be
a very important factor in raising reaction time; nevertheless, words
of equivocal meaning rarely have a very short reaction time. Of the
set of words reading tail, game, eye, poker, currant, soul, all but
poker fall with the students in the range from the third through the
seventh octile. Poker falls in the first octile and was never taken
as referring to a game. With the instructors, all stand as high
as the fourth except eye, which falls in the second. Game alone
stands in the eighth. The same kind of showing is made by the
other classes of subjects and by the other set of words equivocal in
denotation, the list reading altar, medal, patient, bear, cross, tip.
Medal and patient alone stand high with all classes of subjects and
patient, if taken in one sense, is abstract. Curiously enough,
cross was never taken by either students or instructors in its reli-
gious signification and was taken thus only once or twice by the
other subjects. Tip, which in no case stands higher than the third
IO4
Octile, was commonly taken in the sense of fee. Very roughly speak-
ing, the supposedly equivocal words which proved equivocal with
subjects of a given class have long reaction times with that class.
Medal, for example, was frequently taken in the sense of meddle
and frequently in the sense indicated by the spelling. We may thus
make the tentative inference that mutual inhibition between oppos-
ing associations may make itself felt in such experiments as these,
but that usually, when a word is ambiguous, one association
tendency is so much stronger than the other as to suppress it entirely.
Nevertheless, words equivocal in denotation are not quite on a par
with other words, and one cannot know beforehand how they will
act with a given class of subjects. On the other hand, ambiguity
as regards grammatical function seems not to make the slightest
difference in reaction time. The words put into the list to test this
feature are scattered all over the scale.
(3) Words of abstract nature tend to have long reaction
times, unless they are frequently coupled with other words in ordi-
nary speech, as e. g., joy is coupled with grief, or forgive with for-
get. The abstract words on the list may be roughly described for
all classes of subjects as clustering in or about the seventh octile.
Many of them stand in the eighth, but many of them stand as low
as the fifth. Very few stand lower than the fourth octile except
with the instructors, who have, of course, more fixed linguistic as-
sociations than any of the other subjects. The long reaction time
of these words is certainly not due to rareness of occurrence. The
standard nouns include many which are not in very frequent use,
and the abstract words include many which are very common, yet
the standard nouns centre below the median and the abstract
words well above it. It is not because one so seldom mentions
ambition or discouragement that one is so slow in reacting to these
words. If the writers may judge from their own experience, the
hold-up when an abstract stimulus word is given is really due to the
lack of definite visual imagery. The word seems to stand alone in
consciousness for an appreciable interval, whereas when one is
given a word like molasses, one images, say, the fluid itself, and
almost with the image comes such a word as brown or sticky or
jug. It is true that very complex visual imagery may not readily
lend itself to linguistic expression. If one is given the word grocer,
one may “see” a shop and some half dozen different groceries
before a single word will come. This is probably the point which
Wells has in mind when he says that reaction time depends upon
“the tendency of the association to be presented in linguistic form
or in imagery readily resolvable thereto.” Nevertheless, this halt
produced by the thronging of visual images seems different intro-
spectively and is actually considerably shorter than the delay which
|
IO5
occurs when visual images are absent or tardy. In one case, the
field of consciousness seems crowded; in the other it seems vacant,
and one finds oneself repeating “like an idiot” the stimulus word
in internal speech. Perhaps Wells' principle should be rewarded,
for the first image which joins the lonely image of a very abstract
term is usually another verbal image.
(4) Words which refer to sound, taste, smell, tactile or
kinaesthetic experiences have rather long reaction times as compared
with words which refer directly to visual experiences. In the first
place, the nouns in the set reading colic, headache, fever, voice, up-
roar, roughness, all stand above the median except colic and fever
with the students (who almost invariably reacted baby and scarlet),
voice and uproar with the instructors, fever with the patients and
zoice with the uneducated. Headache stands in the seventh Octile
for every class of subjects, although the word is not hard to hear
and refers to a decidedly concrete experience. In the second place,
except with the students, the adjectives in the list beginning sour,
sweet, bitter, taken alone have a median which is considerably
higher than the median of the standard adjectives taken alone. The
standard adjectives, it will be remembered, refer to qualities which
can be seen. The figures are as follows: Median for color words,
taken separately: Students, I.40"; instructors, I.225"; patients,
2.185”; uneducated, I.485". Median for all standard adjectives, in-
cluding color words: Students, I.505"; instructors, I.39"; patients,
2. 39"; uneducated, I.67". Median of the “concrete but non-visual
adjectives”: Students, I.385"; instructors, I.44"; patients,
2.67"; uneducated, 2.13". This showing means more in view of the
facts that such words as sweet, hot and so on readily suggest op-
posites and, therefore, have short reaction times, and that lurid has
a long reaction time because many of the less intelligent subjects
did not know what it meant (indeed two or three of the students
did not). If one compares these sets of figures with the medians
stated on page 561 for all the words given to each class of subjects.
one finds, to be sure, that with the students and instructors, adjec-
tives of all groups centre below the median. However, only the color
words with the instructors and the non-visual concrete adjectives
with the students have really short times. These groups stand re-
spectively in the first and the second octiles. It would be rash to
explain why the students are particularly quick with such words as
sour, hot, heavy and the like. One should have more subjects and
should treat the results in a different way before it would be
permissible even to guess upon so delicate a point. With the patients
and the uneducated, on the other hand, the visual adjectives centre
Delow the general median and the non-visual, concrete adjectives
centre above it. (No unpleasant words, however concrete, are in-
IO6
cluded in the class here taken into discussion.) With the uneducated
as with the faculty, the color words, red, blue and so on centre in
the first Octile. With the patients, the color words centre in the
second Octile. It is curious that with the students they should centre
as high even as the third. º *
(5) Long stimulus words do not in any marked degree seem
to have long reaction times in virtue of their length. In other
words, any retardation which may be due to the lengthening of the
subjects’ reaction time in the case of a long stimulus word is so
slight that it can be masked by almost any of the factors which
tend to shorten reaction time. Of the six words, molasses, gera-
nium, chrysanthemum, rhinoceros, potato, and radiator, with the
students, molasses stands in the first octile, geranium in the second,
and radiator in the third, and only rhinoceros as high as the sixth.
These results are representative, although with the other classes of
subjects the order of the different words is different. Of the twelve
students, seven reacted to molasses with candy, five to chrysanthe-
'mum with yellow, and five to geranium with red, but no such coin-
cidences appear with the other three words. The tendency in the
direction of a single reaction word plus the suggestiveness of a
simple definite visual image is evidently quite sufficient to hide the
effect of length. It must be noted, however, that the long abstract
words do have long reaction times. These six words stand high as
compared with the list of six reading hatred, pride, grief, joy, terror,
'malice, but not as compared with the abstract words at large.
(6) Verbs certainly have rather longer reaction times than
nouns; the case with adjectives is doubtful. In discussing this
point only the standard nouns, adjectives and verbs (throwing out
browse and flinch as ambiguous) are considered as comparable.
The medians for the standard nouns, taken alone, and for the stand-
ard verbs taken alone, are respectively as follows: Students, I.45";
and I.525"; instructors, I.48" and I.625”; patients, 2. I25” and
2.635”; uneducated, I.83” and I.87”. This difference between nouns
and verbs, though constant in direction for all classes of subjects,
and therefore interesting, is not tremendous, and the writers are
not expert enough in the psychology of language to attempt to ex-
plain it. The figures for the standard adjectives, which are the
“visual” adjectives, have already been given (p.562). The students
and patients are slower with the adjectives than with the nouns, but
the uneducated and the instructors are considerably quicker. This
particular line of cleavage makes the results difficult to understand,
and since the subjects are so few, the point is not worth discussing.
It should be remembered, however, that although in comparing one
word with another we are dealing with arithmetical averages which
may be distorted by the erratic results of one or two subjects, yet
Io'7
º
|
when we are comparing one class of words with another, we are
working with medians which are little affected by the extraordinary
positions of a few individual words. One thing, at least, is clear
from this study of grammatical function as affecting reaction time,
and that is that verbs have longer times than either nouns or adjec-
tives. It may be remarked in passing that with our subjects the great
majority of the reaction words were nouns, even when the stimulus
words were adjectives or verbs, although adjectives were more com-
mon as reactions to adjectives than as reactions to other parts of
speech, and the case with verbs was parallel. On the whole, one may
conclude that grammatical function should not be a matter of entire
indifference in making up a list of stimulus words or in interpreting
the results.
The six more important questions of this paper have now been
discussed, but an examination of the results suggests several
other points of interest which can best be brought out by consider-
ing the words which have, for each class of subjects, the longest
and the shortest reaction times. With the students, of the forty
words which stand at the top of the scale eighteen seem to owe
their position to their abstract character and ten to their unpleas-
antness. Among these abstract words, however, are some which
might have tapped emotion in some individuals, as, e. g., love,
which stands high only with this class of subjects made up entirely
of young girls. Among the unpleasant words, moreover, are reek
and writhe, which are hard to hear, and vile which is ambiguous.
Of the other twelve words, four are certainly hard to hear; lurid
carried no meaning to some of the girls, and grocer (taken for
grosser) is ambiguous. Taft, which was the first proper name on
the list, created a little surprise, and ogre was an unusual word in
the girls' vocabulary. One cannot readily tell why the other four
words, shake, mutter, speckled and meadow should stand so high,
especially as nearly every one said hen for speckled and green for
meadow. The five highest words in order are boastful, ambition,
drool, urine, bloat.
With the instructors, the results are very similar as regards
the probable causes of retardation. The five longest reactions are
those for urine, boastful, pus, flinch (ambiguous) and think. Shake
stands high here also but not mutter, speckled or meadow. With
the patients the results are again parallel except that six words,
stupid, fiery, flaming, wicked, courage and patient, undoubtedly owe
their high position to their emotional effect on individual subjects.
The five highest words are in order, stupid, anarious, fiery, future
and discouragement. Unpleasant words come thick after these five,
however, (slobber stands next); they are simply pushed down a little
by the words which have peculiar associations for certain patients.
IO8
With the uneducated, the case is different. Of the forty words
which stand highest, seven are unpleasant; eleven, abstract; one,
(beside vile), ambiguous; one, the very first word to be given; two,
hard to hear; three, words of uncommon occurrence, and three, gen-
eral terms likely to suggest subordinates and, therefore, not so likely
to suggest stereotyped visual imagery as the standard nouns. The
position of the other twelve, however, can be explained only on the
supposition that Cases I and VI found them hard to define and
Case IV hard to match with opposites. Jewel, glove, and pig are
instances in point. The five highest words, if we leave out the one
which was the first to be given when the experiments were made,
are fame, anacious, whistle, glove and pretend.
From an examination of the words with the highest times, two
points emerge in addition to the six already made. In the first place,
words will have long reaction times if they are hard to apprehend
by ear, supposing, of course, that the stimuli are given orally. Wool
stands high with all classes of subjects simply because it is hard to
hear. Nearly every one reacts with sheep. The word is certainly
not unpleasant and all the other textile words stand low. Instances
might be multiplied if time permitted. It must here suffice the
writers to advise other experimenters to avoid words beginning with
zºº, for th or ending with m, n, f, th, or r followed by a mute. More-
over, disyllabic words are distinctly easier to grasp than mono-
syllabic words.
In the second place, words are likely to have long reaction times
"f they are unusual in the subject’s speech life and must switch his
associations into unwonted channels. Ogre stands high even for
the educated subjects, and on this point also examples might be mul-
tiplied. Of course, no rules can be given for avoiding words of this
character.
Turning now to the words which have short reaction times, one
finds that here the ruling principle is the second named by Wells,
the predominance of some single association. In the majority of
cases, the reaction word is a word commonly occurring in proximity
to the stimulus word in ordinary speech. Very often, however, the
reaction word denotes some outstanding visible quality of the object
denoted by the stimulus word, as, e. g., poppy—red. Nevertheless,
all-important as the association law of frequency proves itself in
these experiments, one catches glimpses of another principle. Some
words seem to have brief reaction times because the imagery sug-
gested is pleasant. To bring out these facts, it will be sufficient to
compare the ten or eleven words with shortest times for the four
classes of subjects. These words are, in order, for the students,
scramble, fern (pleasant), purple and tinkle, cherry and curdle and
hot and pigeon (pleasant?), needle and obey and short. (The
IO9
words connected by and have the same time.) For the instructors,
the list runs bitter and kitten, small, black, crimson, green and short
and sour, linen. With the patients, the shortest words are bonnet,
geranium and Roosevelt, scarlet, fester and short, blue and clock,
pretty and robin (pleasant). With the uneducated, one finds robin,
green, purple, grape and kitten, bear, lion, blue, daisy, (pleasant?)
shut and white. The number of color words figuring in these lists
is marked. Do those which have no opposites owe their position to
the fact that they are pleasant? Among the color words purple and
crimson have particularly short times, probably because they have
two syllables and are thus easier to hear than the others. The flower
words, tulip, daisy, poppy, pansy, lily and holly, stand low on the
list for all classes of subjects, but little can be inferred from this
fact since they are the post-critical words and stand severally di-
rectly after such words as stink and pus. The reader can readily
see for himself that many of the words with the quickest reaction
times have one or two word associations which predominate over all
others. Note, for example, scramble—eggs, tinkle—bell, cherry—
red, hot—cold, needle—thread or pin, and so on.
The writers have by no manner of means finished either the
study or the presentation of the experimental results upon which this
paper is based. The evidence even upon the points already made is
a matter of detail and can scarcely be presented in a convincing
fashion within the limits of this report. Nevertheless, from this
cursory examination several suggestions emerge which may well be
taken into consideration in selecting stimulus words for experiments
in chance word reaction. In the pursuit of psychoanalysis this
method has perhaps fallen somewhat out of vogue, but the more
skeptical of the two writers wishes to record the impression that it
1s an excellent means of breaking ground.
In conclusion, the writers wish to thank all those members of
Wellesley College who have assisted in these experiments either as
subjects or as experimenters. They are especially grateful to Miss
Josephine N. Curtis (M. A., 1912), Miss Cecilia Hollingsworth,
1912, and Miss Natalie Williams, IQI3, for material help in the ex-
periments, and to Miss Ethel Bowman, Instructor in Psychology, for
most timely help given at the last moment in the tabulation of the
figures. * Vº
VI
TWO CASES OF MULTIPLE SCLEROSIS WITH OBSCURE
NEUROLOGICAL AND MENTAL SYMPTOMS
(FORMES FRUSTEs)
(PLATES XVII-XXVI)
BY SOLOMON. C. FULLER, M.D., HENRY I. KLOPP, M.D.,
AND MICHAEL M. Jordan, M.D.
The cases reported in this paper seem to us of interest from
at least two points of view: first the obscure neurological and men-
tal symptoms which rendered a clinical diagnosis, if not impossible,
certainly difficult; and, second, the rather prevalent opinion that
multiple sclerosis is a comparatively rare disease in this country.
The neurological symptoms in each of the cases were chiefly of the
spinal type; but Case II, toward the end, presented symptoms
of Cranial nerve, bulbar and cerebral involvement. Mentally
one of them exhibited delusions of a paranoid trend and cer-
tain hysterical traits. In the other case, the almost constant
clouding of consciousness, motor restlessness and temperature
elevation suggested the picture of an exhaustion-infection psychosis,
especially when the immediate antecedent history was taken into
consideration.
With reference to the frequency of multiple sclerosis, well-
known neurologists, such as Prof. Dana’ of New York and Dr.
Spiller” of Philadelphia, incline to the view of a comparative rarity
of the disease in America. But Taylor, among those in this
country who have given serious attention to multiple Sclerosis, as-
sumes a skeptical attitude as to its infrequency. He believes that
many cases escape recognition, and more, that it “is a common, or-
ganic disease.”
Aid in clinical diagnosis had been sought in each of the cases
here reported, by consultation with neurologists and psychiatrists
of wide reputation, who from time to time had visited the hospital.
The correct diagnosis, however, had never been suggested: it
was established only after autopsy. Among the possible condi-
tions which had been considered, were hysterical astasia abasia,
and possibly a luetic or tubercular meningo-myelitis, for the first
case; and for the second, meningitis, meningism, meningo-ence-
phalitis, meningo-myelitis, exhaustion-infection psychosis and “qua-
Si systemic” spinal disease (Putnam-Dana type). The writers had
favored the last mentioned, for reason of the associated secondary
anaemia, spinal symptoms of motor and sensory character, exten-
sive areas of bronze-like pigmentation of the skin, general mus-
cular wasting—particularly in one of the cases—and the pre-
terminal paraplegia in both of them.
I T2
In Case I, the “insular scleroses” were most numerous and
most extensive in the spinal cord. In the medulla and pons these
areas were not only rarely encountered, but were also very small,
barely perceptible macroscopically. In the cerebrum of this case,
none of the characteristic lesions were found. In addition to small
blocks of brain tissue, sections were made on a microtome for
whole brain sections, and stained for the display of fiber tracts;
but the entire cerebrum was not sectioned serially, only the area
limited by the anterior and posterior extremities of the corpus
callosum. Moreover, the blocks were extremely brittle and com-
plete sections were difficult to procure, so that an unbroken series,
even for this area, was not obtained. In Case II, extensive and
numerous lesions were shown in the spinal cord, medulla, pons and
cerebrum, in the last mentioned region, some rather large lesions;
and particularly were they present in the neighborhood of the ven-
tricles. All of these disseminated sclerotic areas conform, in the
main, to the classical descriptions of multiple Sclerosis; and yet, as
has been noted, the clinical symptoms, to say the least, were
misleading. In the light of the completed histories, certain
clinical data, perhaps, had not been given their due consideration.
It is far from our intention to present these two cases as evi-
dence of the frequent non-recognition of multiple sclerosis, but
rather as two cases with clinical symptoms that were certainly
baffling, and which would have remained “innocent” of a correct
diagnosis without autopsy. Incidentally, they also serve to call
attention to the somewhat protean character which the disease may
assume clinically, as exemplified in Case II.
The history of these cases is as follows:
CASE I.—No. 7368, an unmarried women of forty-six years
was admitted to Westborough State Hospital, April 12, 1907.
Family History.—Father died at the age of seventy-six from a
cardiac affection; mother living, aged 82, but suffers from some form
of heart disease which is not definitely described. Two brothers
died in infancy of cholera infantum; one sister has pulmonary tuber-
culosis; four sisters and two brothers are living and enjoy, fair
health. A grandfather died at the age of 70, cause unknown; a
grandmother at the age of 46 from “cancer of the stomach”. One
aunt was insane. All of the family are reported as more or less
“nervous”. Father and mother are first cousins.
Previous History.—The patient, seventh in a family of ten
children, states that, as far back as her memory goes, she has al-
ways been a nervous person; that she had diphtheria as a child,
when a young girl a sunstroke and once fell from a hay loft; that
many years ago she had some “head trouble” and an ear affection;
and that throughout her life she had been subject to frequent at-
II3
tacks of tonsilitis. Menstrual function was established at the age
of fifteen and a half years, but soon after ceased for about two
months. At this time there was something the matter with her
head and there was also a discharge from one of the ears. The
character of the head affection was not definitely described; the
discharge from the ear was evidently, from her descriptions, the
result of middle ear disease; neither was associated with the sun-
Stroke or fall noted above. Her knees, she says, have always been
weak, and ever since her twelfth year she has experienced, off and
on, “creeping sensations” in the lower extremities. Of late, these
parasthesias have increased and she has had difficulty in walking.
She has been treated at several sanatoria for these conditions but
without any favorable result. -
In 1890 she had a severe attack of influenza, and in 1894
typhoid fever and pneumonia. In 1899 she suffered what is de-
scribed by the patient and her friends as a “shock”, but there was
never any loss of consciousness. This “shock”, from the descrip-
tions given, appears to have been a sudden culmination in an
inability to walk. For some little time prior to this affair the par-
asthesias described above had been more severe; there had been also
considerable numbness of the legs and feet, causing her to
stumble frequently. Finally, one day while out for a walk she
fell and could not get up unaided; when assisted to her feet she
claimed an inability to walk without support, but this latter her
friends had doubted. Ever since this occasion she has been afraid
that she would fall and injure herself whenever she attempted to
walk, and since then she has walked but little; in fact, soon after
she ceased walking.
The mental make-up of the patient, her friends say, has al-
ways been vascillating, moody and reserved. Since 1891, a marked
change in her disposition has been noted: she has been fault-
finding, deceptive to her relatives, would not comply with reas-
onable requests, communicated her fancied grievances to stran-
gers, wrote complaining letters to city authorities and to the of
ficials of sanatoria at which she had been formerly a patient. On
One occasion, before she ceased walking, she had attempted to run
away from home and recently has wanted to jump from a win-
dow. She explained these actions as only attempts to get medicine
for her illness which relatives did not provide, since none of them
believed she was ill and all of them were persecuting her. She had
been very bitter, especially against a brother. Lately, she has
become very slovenly in habits and untidy in her person. She
has developed the idea that, in addition to the trouble with her legs,
she has other serious diseases.
Here.—On admission, a poorly nourished, middle-aged woman,
II4
5 ft. 4% inches tall and weighing 7534 lbs., presents a very
Striking bronze-like pigmentation of the skin of face, arms and
anterior surface of the trunk and thighs. On the dorsa of the
hands are leucodermic areas, some of these sharply defined by the
pigmented areas, others less so. The rather elongated face, high
cheek bones and the peculiar bronzing of the skin of the face sug-
gest the features of an American Indian. She appears unable to
walk without support on each side, even then the gait is ataxic.
There is slight dorsal scoliosis, right. The heart's action is weak
but regular and a faint systolic murmur is heard; pulse 80; respira-
tions 24 per minute, prolonged expiration. The tongue is heavily
coated, except for its borders, where it is very red; bowels loose,
but no incontinence of feces or of urine. A blood examination re-
veals erythrocytes 3,000,000 per cmm. leucocytes 6,000, Hb. 45.
The pupils are equal, reacting to light and accommodation,
although the left pupil reacts rather sluggishly to light. No sen-
sory or motor disturbance of cranial nerves detected. Knee jerks
elicited, somewhat exaggerated; double ankle clonus and a ques-
tionable double Babinsky; wrist, pectoral, jaw and abdominal re-
flexes active. The pharyngeal reflex is absent. There seems to
be a rather general diminished pain and tactile perceptibility, par-
ticularly on the chest, over the mammae, and the upper three-fourths
of the back. Coordination tests are poorly executed. She complains
of numerous paraesthesia of the trunk, abnorminal viscera and ex-
tremities, and also of almost constant pains in the legs and arms
which she calls “neuralgia”. She says she is chilly all the time,
and that is the reason for being clad in three suits of heavy under-
wear, although it is mid April and the temperature is fairly warm.
The speech is a little indistinct, something of a lisp, but in good
tempo and without stumbling over test phrases.
Mentally she was without true insight into her condition; ex-
pressed delusions of persecution, chiefly against her relatives; and
related various subjective symptoms which to her mind indicated
clearly certain diseases—cancer of the stomach, large abdominal
tumor, etc. Her general manner was somewhat affected and in
many little ways her conduct suggested a bid for sympathy. When
her stories of ill treatment did not arouse in the examiner a parti-
san feeling for her, and when certain special inadvisable favors
were denied her, she became quite irritated and was just a bi
abusive. -
During the six weeks following her admission, she was con-
stantly demanding of the nurses some attention, making no effort
to aid herself when they were near but managing quite well when
alone. Any failure to immediately grant her requests, whether rea-
sonable or not, was at once spoken of as abuse from the hospital
II5
personnel. She still retained the ideas of persecution on the part
of her relatives, and while the disturbance in gait was no better,
she had gained in weight, appetite was good and she was sleeping
better. - .
Eight months after her admission, she complained that she
could no longer move her lower extremities. An examination,
however, showed that when each leg was lifted from the bed she
could hold it up for quite a half minute before letting it fall, and
when gotten up and assisted she could walk quite as well as on ad-
mission. Much to the astonishment of the examiners she did even
better when walking backwards, but she apparently could not go
alone. The legs were stiff, somewhat abducted, and in walking the
gait was now distinctly steppage in character. The areas of dim-
inished pain and tactile perceptibility were still present, and ques-
tionable anaesthetic areas were delimited on the anterior thoracic
wall and on the face. Sometimes cold and warm stimuli were cor-
rectly differentiated, sometimes not. The knee jerks were extreme-
ly active and the reaction of the great toes to plantar stroking, the
examiners concluded was a positive Babinsky reflex.
The patient's condition remained very much as has been stated
for two years, when the bronzing of the skin, noted on admission,
began to increase. Often these areas started as small brownish dis-
colorations which did not exceed 2mm. in diameter, and rapidly
extended to irregular areas 8 to 12 cm. or more, in their greatest
extent. Leucodermic areas of the hands became more pronounced,
and appeared also on the face, trunk and extremities. These leu-
codermic spots developed in the portions of the skin which had be-
come pigmented, usually in the portion of the bronzed patch which
was the first to become discolored, all of which imparted a distinct-
ly piebald appearance. An examination of the urine at this time
was negative for nephritis and also for glycosuria. The area of
cardiac dulness was not enlarged; the heart sounds muffled and a
faint haemic murmur detected. Blood examination: erythrocytes
I, I2O,OOO ; leucocytes 3,OOO ; Hb. 20; many poikiolocytes; nucleated
red cells encountered; few myelocytes.
The lower extremities exhibited considerable atrophy, partic-
ularly the left; still, there was general wasting of the entire mus-
culature. Coordination of upper extremities was fair; incontinence
of feces and urine had developed; and there was no longer any
question as to paraplegia. -
The patient died after a hospital residence of two years and
five months, during the last six months of which she had steadily
gone downhill, the last six weeks rather rapidly, having developed
an extensive decubitus.
At no time were intention tremor, nystagmus, or scanning
speech noted.
II6
Anatomical Diagnosis.-Increased density of calvarium, anaemia
of brain and meninges, pial opacity and edema, sulcus semilunatus
On each occipital convexity, multiple focal degenerations of the
spinal cord; hydropericardium, cardiac atrophy and degeneration
of the myocardium, thickening of mitral and aortic cusps; t. b. of
peribronchial lymph glands, anaemia of lungs: Glissonitis, anaemia
and amyloid (?) degeneration of liver; anaemia and parenchymatous
degeneration of spleen; hyperplasia of right adrenal; anaemic kid-
neys; bronzing of extensive areas of skin and numerous leucoder-
mic patches; extensive gangrenous decubitus.
CASE II.-No. 9523, a woman of thirty-three, and wife of a
clergyman, was admitted to Westborough State Hospital, April 21,
I9II.
Family History.—Nothing of importance is elicted in the fam-
ily history as furnished by the husband and relatives of patient.
Previous History.—The patient is the second of five children
and is reported to have been healthy as a child and up to the onset
of the present illness, with exception of a severe attack of measles
at the age of seventeen, from which she made a good recovery.
She was a very affable person with a healthy attitude toward life.
After graduation from high school, in 1900, she became the private
Secretary to the president of a prominent New England univer-
sity, a position with not a few responsibilities, which she had filled
Satisfactorily until her marriage seven years later, October 1907.
After marriage she did her own house work. She had borne
two children rather close together, the youngest now a year old.
The last child was a heavy baby and the care of the two children
had been especially trying, all the more so with the usual house
work to do, for ever since shortly after the last lying-in period she
had been without assistance. She never quite recovered her usual
strength. All of the previous fall and winter she had been very
tired, but had managed to keep her home in order and even in-
dulged in considerable of the social life of the parish which, as the
minister’s wife, was more or less obligatory. About February 1911,
the strain began to tell—she was begining to be nervous and de-
pressed—but she kept up until March I, when she had to go to bed.
She has gradually become helpless from loss of power in the
extremities, particularly on the right side. At first, the intensity
of the impairment seemed to vary, sometimes within a very short
period. For example, one morning she left her bed to go to the
living room, where for a few moments she stretched herself on the
couch. When she got up to return to her bed she fell to the floor
and could not get up unaided. She was not unconscious, for she
called to her husband for assistance. He carried her to the bed
and placed her on it, but a few minutes later she was able to get up
|
II.7
}
and walk alone. After this, however, it was noticed that she fre-
quently stumbled and that the gait was becoming more and more
awkward; finally she was unable to stand alone. She was consti-
pated and the enemas given for this condition had to be siphoned
off, there seemed to be insufficient power to expel them; the urine
also had to be catheterized. A cystitis had developed which had
been treated with autogenous colon bacillus vaccine, but apparently
without good result. For the last week the stomach had become
intolerant of food and she had to be nourished per rectum. Menses
had been regular and had never been associated with much pain.
Recently she has shown a considerable impairment of memory;
she has been irritable; cried and moaned a great deal; and ex-
pressed a wish that she might die, but has made no attempt at
self destruction. She has frequently appeared confused.
Here.—On admission, a fairly well-nourished young adult
woman who unaided, apparently, can not stand or walk. An ex-
amination, though unsatisfactory, reveals the following: tachycar-
dia but regular heart's action, no murmurs, no increase in the area
of cardiac dulness; normal respiratory sounds. The tongue pre-
sents a heavy yellowish coating with a central, brown streak. She
is constipated; and there is a constant dribbling of urine. No pa-
thological alterations are detected in the abdominal organs. The
uterus is retroverted and slightly prolapsed; there is some leu-
corrhoea, and the perineum is torn. The skin is without eruption,
but she is decidedly dark, very little difference in color between
the usually exposed and non-exposed parts.
The pupils are dilated, the left more than the right, and react
sluggishly to light. She does not cooperate in tests for accommoda-
tion, in the determination of the field of vision, or in the attempt
to examine the eyegrounds. There is apparently no defect of hear-
ing, nor in the ability to discriminate between pleasant and un-
pleasant odors, or detect salt, sugar, vinegar and a bitter substance
placed on the tongue. There is a hyperaesthesia of the gross tac-
tile perceptibility but the finer epicritical touch could not be defi-
nitely determined for lack of cooperation. Moreover, she com-
plained that the examinations were painful, constantly wincing and
making protective movements excessively out of proportion to the
amount of stimulus employed, and with it all a certain amount of
rigidity was engendered, particularly in the lower extremities and
abdominal muscles. Still deep pressure over the spinal nerve
roots and over nerve trunks was not especially painful. She would
not undertake the tests for coordination of the upper extremities,
nor cooperate in the tests for muscle sense. All tendon reflexes
could be elicited, most of them exaggerated. Ankle clonus, and
Babinsky and Oppenheim reflexes were present on both sides;
the abdominal reflex was not elicited; no tremors.
II.8
Mentally, she was depressed, and questions seemed to annoy
her—she wanted to be left alone. During the first night at the
hospital she was noisy, talking loudly almost incessantly. She
complained of a great deal of pain in the abdomen and added that
she wanted to die. She would throw herself from the bed to the
floor, but always took the precaution to put the pillows on the
floor just about where she expected to fall. She persisted in this
at intervals up to about 2 a. m., when she was ordered placed in a
dry pack to prevent injury. After she was placed in the pack she
was very noisy the remainder of the night. The next morning
she did not cooperate with the examiner—she still did not wish to
be bothered. To most of the examiner's question she would re-
ply, “I don’t know anything”, “Don’t ask me questions like that”,
or, “Please don’t; ask my husband, he'll know”. She was apparently
not oriented. She still did not want to be touched and she would
cry out every time she was touched on the trunk or a tendon
tapped with the hammer. At times, during the examination, it was
doubtful as to whether or not she was delirious. For example,
during the examination she said, “Andrew, will you pleose ge
away, you pretty nearly killed me”. Andrew was not the name
of any person present, nor so far as we could learn of any near
relative or intimate friend. Again, “Father, please take me away,
it’s pretty near killing me. Take me away, it hurts me so. Oh!
Take those stars away.” Once she said, “I can’t see, it hurts my
eyes so. I can’t breathe, it makes me sick”, all of this interjected
after reply to the question “Who am I,” to which she had answered
Oh! Don’t touch me you hurt me so. Oh! I wish I were dead.
“The whole push”. Later on in the interview she again voluntarily
referred to her eyes by saying, “It hurts my eyes so to look
around”. t
April 27, 1911. Since the first night after admission, six days
ago, she has made no further attempt to throw herself from the
bed, nor has she been noisy, but she has been very restless in bed,
constantly untidy, for the greater part of the time apparently un-
conscious, talking in a rambling and incoherent manner of old ac-
quaintances and past experiences. She could be aroused at times
from this apparently delirious state, but the attention could be
held only for a few seconds. She did not pay the slightest notice
to her surroundings, usually staring vacantly into space. The gas-
tric intolerance reported on admission had disappeared, for she
had taken a liberal amount of liquid nourishment which had been
retained. The hypersensitiveness to touch which in many re-
respects had simulated a central neuritis, had also disappeared, or at
least she submitted to examinations requiring manipulations with-
out protest. The skin of the abdominal wall, from a point on
II9
level with crest of ilia to about level of lower border of sternum,
and laterally extending to the axillae, presents a pigmentation,
brownish with yellowish flecks, which does not appear to be the
result of bruises. Within the pigmented area there is also an area
of leucoderma extending along the lower border of the ribs on the
right side. The pupils are dilated and unequal, the left larger than
right; both very sluggish to light. The eyegrounds could not be
examined for lack of cooperation; there is a conjunctivitis of the
right eye with injection of the lower half of the cornea.
May 6, 1911. Until yesterday there had been but little change
in her condition, as described in the last note, except that high
enemas had brought about less frequent involuntary defecation,
when she suddenly became much worse, developing a temperature
of IO2.2 F, pulse I30, respirations 24. She was quite noisy, calling
out loudly certain numbers, sometimes in a stereotyped manner,
sometimes without any order, her right arm in the meanwhile con-
stantly in motion while the left arm was flaccid at her side, as
though paralyzed. Babinsky and Oppenheim phenomena, which
heretofore could be elicited on both sides, could now be demon-
strated on the left side only. Moreover, all tendon reflexes were
much more active on the quiet left side. Whether or not this was
due to a certain amount of resistance of the actively moving
right arm could not be definitely determined, but it did not seem so.
The temperature at midnight was IO3.2 F., pulse I24, respirations
24; at 6 a.m. this morning IOI.6 F., pulse I29, respiration 24; and
at 9 a. m., IO2.2 F., pulse I30, respirations 24. The heart’s ac-
tion is very weak, the first sound very distant.
May 8, 1911. There is some slight improvement. The tem-
perature is lower, IOO.8 F.; it has been as high as IO3.6. Both
sounds of the heart are heard distinctly, she is less noisy and talk-
ative and the clouding of consciousness is less profound, that is,
she can be more frequently aroused for short periods. When her
husband visited her today she answered two or three questions,
which he asked her, in an orderly manner and appeared to re-
cognize him. She lies with her head thrown backward and the back
slightly arched, but there is no resistance to passive movements of
the head or extremities. Yesterday the pupils were equally con-
tracted, about 2 mm. in diameter. Today they are widely dilated
and equal. There is slight nystagmus of the eye globes. The
tendon reflexes on the right side are very active, those on the
left side much less so, just the reverse of what has been previous-
ly noted.
May 13, 191 I. Since the last note the temperature has oscil-
ate between IoI and IO3 F. A test for the Widal reaction, made
today, is negative. Blood count: erythrocytes 4,000,000, leucocytes
I3,OOO, Hb. 50.
I2O
May 25, 1911. The temperature registers IOO. 4 F. Clouding
of consciousness persists. She is almost constantly making aimless
movements in the air with her upper extremities, the hands firmly
clenched meanwhile. The lower extremities are flexed and well
drawn up, but there are no contractures, since they can be straight-
ened without any resistance, but she gradually flexes them again.
The toes of the right foot are now and then flexed or extended
voluntarily. There is little or no reaction to pin-pricks anywhere
On the lower extremities, but she draws away when the trunk, arms
or face are pricked. She resists passive movements of the arms.
The knee jerks can not be elicited; hitherto they have been very
active. Babinsky phenomena is present on the right side, a very
questionable reaction on the left. Oppenheim reaction present on
right side, none on left. She either moves her lower jaw from
side to side, or calls out loudly certain letters or numbers, for
example, “P. R. TH. K. I2. L. K., a part of it too. 21.
K. S. LL. K. K. S. L. 21. K. O. Y. Z. Z. F. L. L. T. Y. S.
S. O. O., etc. Occasionally these are interspersed with the fol-
lowing phrases: “24th case suddenly”, “23 case remember, case
suddenly”. “Wont you tell me?” “For Ma's sake suddenly”. “K.
A. suddenly represents the first word suddenly, A. Z. O. plus Y.,
his word is always important”, etc.
May 29, 1911. At about 6 p.m. of this date she had a general
convulsion which lasted about two minutes.
May 30, 191 I. She is very restless, keeping the arms mov-
ing constantly, picking at the bed clothing or waving them in the
air. She is also very talkative in much the way as noted above,
“practical, compromising, retroside, Stranger”. “The frat word
bothers me, occasion would say fraction now”, etc. Diarrhoea and
constipation have alternated for the past week or more.
May 31, 191 I. The patient was noticed for the first time to
move the lower extremities freely from side to side and to lift them
from the bed.
June 2, 1911. She remains much the same, temperature fluc-
tuates between IOI and IO2 F.
June 7, 1911. At noon today the patient had clonic spasms of
the right arm and left leg. At one o'clock there was another con-
vulsion, during which the mouth was drawn to the right, the tongue
in active motion but not protruded, the right arm and shoulder
muscles, the right leg and foot convulsed. The left side
was not involved. After the convulsion, which lasted about
two minutes, the tendon reflexes were very active on the left
side; elicited with difficulty or not at all on the right side. After this
there were two other seizures before 2 p.m., of the same character.
At 2.30 p.m. convulsive movements less than a minute's duration
I2I
&
º
were confined solely to the right side of the face. Between 3.30 and
4. I5 p. m. there were several attacks, some of them with right
facialis phenomena alone, others with right side convulsions of the
entire half of body. *.
June 15, 1911. No further convulsions have been observed
since the last note, but the patient’s general condition seems worse;
she is almost constantly delirious and the cystitis is decidedly
worse. For this condition autogenous colon bacillus vaccine is
given and irrigations of the bladder. She has to be tube fed.
July 1, 1911. There is some contraction of the lower ex-
tremities, more marked of the left. Passive movements of the
knee joints attended with great pain to patient. There is less
incontinence of bowels.
July 28, July 30, 191 I. The hospital masseuse reports a fixa-
tion of not only both knee joints, but also of both hip joints.
Extension treatment by means of graduated weights was begun.
A bed sore has appeared over the sacrum. There is some slight
diminution in the amount of pus in urine. The temperature, never
below IOO F., has begun to rise again. A blood count shows the
following: erythrocytes 3,000,000, leucocytes I7,500, Hb. 35; no
pathological forms of red cells suggestive of pernicious anaemia.
The pigmentation noted above is more intense and more diffused,
most marked on the face and hands. Up to two days ago she had
been treated in bed on the verandas, and whether or not this has
been responsible for the more intense pigmentation of the hands
and face it is difficult to exclude, but the non-exposed parts of the
body have also become darker. The tendon reflexes and neurolo-
gical symptoms still show a tendency to vary, now present on One
side, now absent. &
July 29, 1911. About midnight, last night, after a day without
unusual symptoms, the physician was hurriedly summoned. Find-
ing the patient almost pulseless, face livid, apparently choking and
lying on her back with head and eyes turned to the left and with
widely dilated pupils, artificial respiration and hypodermatic injec-
tions of whiskey were employed. After five minutes, respirations
became normal and the pulse was better. Towards morning she had
a similar but less severe attack.
There is a rather pronounced brownish pigmentation of the
skin, most pronounced on face.
Aug. I, IQII. Symptoms of bronchitis; considerable mental
confusion; motor restlessness. The bed sore noted above is ex-
tending, others are appearing. Diarrhoea with frequent greenish
yellow movements; urine still purulent.
Aug. 8, 191 I. She is noticeably weaker; pulmonary consolida-
tion, both sides. At 3 p. m. choking attack as described above for
}
I22
H
July 29. She was almost pulseless but responded to hypodermics
of brandy and Strych. Sulph. I-30 gr. Again at 8 p.m. inability to
Swallow; temperature IO3 F.; pulse I46; respirations 50 ; profound
unconsciousness.
Aug. 9, 191 I. Death at II.48 p.m.
Autopsy IO hours post mortem.
Anatomical Diagnosis.-Increased density of calvarium, tense
dura, edema of pia, Small focal areas of pial opacity, anaemia of
brain, grayish-pink focal areas in white substance, particularly in
neighborhood of ventricles and also involving portions of gray
Substance of cortex, and in basal ganglia (sclerose en plaques), anae-
mia of cord, diminished consistance, multiple grayish-pink areas
involving sometimes white substance alone, sometimes gray sub-
stance also, and missed altogether in other segments; acute de-
generation of myocardium; acute pleuritis, double lobar pneu-
monia; hypertrophy of spleen; anaemia of spleen; enteritis; anaemia
of kidneys, purulent cystitis, uterine retroflection; decubitus.
Microscopical Earamination.—The chief features of the stained
sections are the multiple areas of disseminated sclerosis within
the central nervous system and their indiscriminate distribution.
The descriptions, therefore, will deal chiefly with these areas. Of
the body tissues, we would call attention to the hypertrophic
adrenal mentioned in the anatomical diagnosis of Case I. The
size and shape of the adrenals in cases coming to autopsy at
Westborough have been found to be variable without altering
in any essential manner the histological components of the glands.
In Case I it seems, we have only a simple hypertrophy of
the suprarenal. The parenchymal cells stain well and offer no
marked alterations, except in those portions where there is usually
an abundant fat content, these sections exhibit little or none. The
pneumonic process in Case II had reached the stage of gray
hepatization.
Pia.-In Case I, the pia exhibits a moderate proliferation of
connective tissue fibers and large endothelial cells, some thick-
ening of vessel walls, edematous distension of the connective tis-
sue fibres and in some areas comparatively large masses of yellow
pigment deposited free in the mesh. There are no infiltrative phe-
nomena. The pia of Case II shows much the same condition ex-
cept in certain areas—areas of focal opacities mentioned in ana-
tomical diagnosis—where there is a moderate lymphocytic and
Abraumaellen infiltration.
Cortex-In case I, the sections of the cortex, from blocks
fixed in alcohol and stained with toluidin blue after Nissl, offer
little that is of significance. There is an increase of glia nuclei
which is rather general in its distribution, and ganglion cell atro-
I23
phies, cells which stain rather deeply. Many of the Betz cells show
a rather marked central chromatilysis, with displacement of the
nucleus to the periphery or complete extrusion. When the former
condition exists (peripheral displacement of nucleus) the cell
appears swollen; when the latter (nuclear exclusion) it is shrunken.
Interesting in this connection is the appearance of such cells in
Bielschowsky silver impregnated sections. In the chromatlytic
areas there is a decided tinging of the interfibrillary substance and
ill defined and swollen, or complete disappearance of fibrils within
the area, while the remaining fibrils of the cell show good preser-
vation or at most beginning rosary formation. (Fig 6). There is
slight, if any, progressive alteration of the vessel walls, but oc-
casionally one sees regressive changes of the endothelium of cor-
tical vessels and in some of the larger calibered vessels pigmented
macrophages within the adventitia. Infiltration of the perivascular
spaces with plasma, lymphoid or mast cells, fails completely in all
of the sections examined. Throughout the cortex, particularly in
Sections from the central gyri, large glia cells with abundant pro-
toplasm are more frequently encountered than is usually the
case with vascular changes no more severe than are here shown.
In the white substance, these glia and vascular changes are more
pronounced, but even here the process can not be considered as
extreme. Mann and acid fuchsin-light green stained sections, after
Weigert’s glia mordant and Flemming's fixative respectively, add
little to what has already been described for the cerebral cortex
of this case.
In Case II, the cortex is replete with changes which may
well be considered as acute, but there are also changes, of the ner-
vous apparatus at least, which may just as well be interpreted as
chronic—ganglion cell atrophies—and likewise of the mesoblastic
apparatus—progressive-regressive vascular alterations, and vessel
proliferation. The acute histopathological changes, however, dom-
inate the microscopical field. In alcohol fixed material stained with
toluidin blue, many large glia cells with abundant protoplasm and
numerous processes are encountered. The nuclei of many of these
cells are seen undergoing direct division. Other large cells with a
Small darkly staining nucleus which is usually eccentrically placed,
presenting a considerable protoplasm of net-like structure, are also
seen. These cells ar either round, oval, or somewhat saddle-
bag shape, and are usually found in groups. Occasionally one en-
counters a fairly well circumscribed area of from 9% to 34 of the
field of a low power lens in which only a few darkly stained and
atrophic ganglion cells are shown, sometimes with and sometimes
without the large cells last described, the intercellular structure of
the whole area presenting a distinct, relatively coarse-meshed
I24
appearance. These areas in Nissl specimens and also in Bielschow-
Sky sections present much the appearance which Fischer has des-
cribed and illustrated as spongiöser Rindenschwund. But in material
fixed in Weigert’s glia mordant and Flemming's solution, and
stained with Mann's eosin-methylene blue mixture, Mallory's phos-
phomolybdic haematoxylin and fuchsin-light green they are shown
to be none other than minute microscopic areas of “insular Scler-
osis”, Figs. 7, 8, for they present the histological characteristics
shown in the larger macroscopic areas of multiple sclerosis found in
the cord and other regions which are to be described later. These
minute areas, as well as the groups of large cells, are more com-
mon in the white substance than in the cerebral cortex. As to their
regional distribution in the cerebrum they were more frequently
seen in blocks from the lips of the calcarine fissure, the central gyri
and paracentral lobules.
In Weigert myelin sheath preparations of large sections of the
cerebrum of Case II, and transverse sections of pons, medulla and
spinal cord of each of the cases, macroscopic areas of “insular Scler-
osis” are frequently exhibited. These areas, as in the classical des-
criptions, follow no definite fiber tracts, and affect indiscriminately
gray and white substance. Figs. I, 2, 3, 4, 5. In the cord, very strik-
ing is the manner in which one segment may be involved, perhaps on
one side, or both, and in the very next segment, it may be, the op-
posite side would be affected or perhaps the whole segment escape al-
together. In the cerebrum the involvement of fibers in the neigh-
borhood of the ventricles, particularly the lateral ventricles and also
the 4th, was very common in Case II. The involvement of the spinal
cord in Case I was just as extensive as in Case II, large lesions ceas-
ing abruptly at the medulla, only very small lesions, barely percepti-
ble to the unaided eye, were seen in the medulla and pons, and
none were found in the cerebrum, not even microscopic areas and
that, too, with the more refined methods such as Mann's stain and
acid fuchsin-light green. In Case I, the lesions in the lower half of
the cord were less indiscriminate in their distribution and more
“quasi systemtic” in character. Fig I. When the multiple sclerotic
areas are examined in sections stained by the methods last mentioned
and by Weigert’s glia method, it is readily seen that there is a mas-
sive proliferation of glia fibers and, save at the periphery of the
lesions where glia fibres are less numerous, axis cylinders are very
rarely found, in some of the older patches none are shown. Al-
ways within these areas, most numerous in the peripheral portions,
but also where glia fiber proliferation is pronounced, are certain
large cells of phagocytic character which have been already men-
tioned. Figs. 8, 9, II. These cells are commonly referred to in de-
scriptions of multiple Sclerosis as “compound granule cells” and are
I25
also to be found crowding the perivascular spaces of blood vessels
in the vicinity. Fig. Io. These cells we believe to be chiefly
of glial origin,” despite their presence in the walls of vessels.
Not infrequently an axis cylinder may be seen in cross section in
the protoplasm of such a cell or an axis cylinder with myelin sheath
still intact either completely or in the process of being enveloped,
by an indentation at the periphery of the protoplasm of the cell,
or an extended and slightly curved pseudopod; occasionally
even an amyloid body. Fig II. In fuchsin-light green specimens
certain bright red granules (inchsinophile granules) are seen but
not in great number nor in all of the cells (see Fig. 9) and also
with Mann's stain certain blue granules which do not appear to be
identical with the granules just mentioned. Amyloid bodies are not
only frequently seen in the sclerotic areas, but also in the other areas
of the cord. In Case II they were also found in the cerebral cortex
and white substance, though less frequently. The clear round
Spaces or holes so frequently mentioned by authors, are shown to
be residuals of these large cells which have disintegrated, and rests
of the net work of the protoplasm or even of the nucleus may be
made out in the specimens stained with fuchsin-light green. Fig. II
Attention would be called to the condition of the optic commissure
as shown in Fig. 4. It is seen that, except for a narrow rim, there
is almost a complete destruction of myelin sheaths. It is possible
that the pains complained of in the eyes clinically may have been due
to this condition, and it is also probable that a greater impairment of
vision existed than was apparent while the patient was alive.
The anatomical changes which have been described, we believe,
prove that these cases properly belong to the clinical group known
as multiple sclerosis (sclerose en plaques, “insular sclerosis”) and al-
though clinically not corresponding to the classical type are best
grouped perhaps, with the so-called formes frustes under which
Redlich" Taylor" and Charcot' believe more cases course than under
the classical type of Charcot.
From the standpoint of etiology, assuming that the previous
histories as recorded give all of the essential facts, then, for Case II
a great rôle must be assigned the puerperum, for there is little
*This view of the nature of these large cells is the result of much reflection. For quite a
long while we had considered them as Abraumzellen of mesodermic, origin which, Merzbacher
describes (Wissls u. Alzheimers Arbeiten, Bd. 3, p. 1, 1909), and it may be that such they are. To
be sure they are much ſess numerous in the oiâériësions where there is considerable glia over-
growth than in the yº. lesions where glia fibre proliferation is scant, but there are few lesions
either in the brain or cord, which are altogether free from such cells. Moreover, in recent as wel
as in old lesions, they are most numerous at the periphery. It is just at such points that one is
most likely to encounter a reactive cellular gliosis. As shown in Fig. II, one sometimes find
them including not only axiscylinders with their myelin sheaths, but also amyloid bodies. Their
presence in the perivascular spaces of nearby vessels is not inconsistent with their glial origin.
Alzheimer has recently and convincingly shown that certain type of glia cell º be found under
certain conditions within the perivascular spaces of blood vessels. (Nissls u. Aſzheimers Arbei-
ten. Bd. 3, p. 401, 1910.). See also A. Jakob., Nissls u. Alzheimer's Arbt. Bd. 5 pp. 1-182, concerning
the type of Abrazemzellen. This paper we learned of after ours had gone to press. The views
are much the same.
I26
else to which an etiological factor can be attached—a causative fac-
tor frequently noted in the literature. The rapidity with which the
case developed and its constantly progressive character while in
hospital, classes, it, if not acute, at least as of subacute character.
With Case I, while chronicity is evident, going back to the twelfth
year, the etiology may not be disposed of so readily. We have
in the fall from a hay loft many years ago, together with the long-
standing paraesthesias and frequent attacks of angina tonsilaris, the
possibility of a traumatic as well as an infectious origin. While
trauma and infection have each been assigned as factors in the
etiology of multiple sclerosis, the latter has aroused considerable
discussion, good Observers being found as proponents and equally
good observers as opponents. As to trauma, Redlich" advises cau-
tion in assuming this as an etiological factor, although believing
it is the cause in some cases. We would mention in this connection
the case of a young man, still a patient at Westborough, who de-
veloped the symptoms of multiple sclerosis following a fall from
the roof of a shed to the court yard, a distance of about 20 feet.
He was admitted to hospital when nineteen, about five years after the
accident, and has been in hospital for about four years. At pres-
ent he exhibits all of the classical symptoms of multiple sclerosis,
but at first and for about a year after admission he was considered
a case of dementia praecox.
The gait in Case I showed, in addition to the motor symptoms
which were described in the record, an ataxia. In view of the
question which some raise as to whether or not the ataxia ex-
hibited in such cases is to be interpreted as a sort of intention tre-
mor, this observation in Case I seems to us of interest. But we
do not take sides, since the observation was recorded only in the
early part of the history and not noted subsequently. In Case I,
sensory symptoms—pain, paraesthesias, chilliness and anaethesias,
were frequently complained of. In Case II, the tenderness to touch
which suggested a central neuritis was quite prominent for a short
while, but diminished pain sensation in lower extremities was
rather continuous, or at least so appeared, the frequent clouding
of consciousness rendering an accurate determination impossible.
Finally, we could call attention to the psychical disturbances of
multiple sclerosis as exhibited in these two cases and two others
which we have observed at Westborough. To be sure, mental dis-
turbances, as appearing among the clinical symptoms of multiple
sclerosis, have been noted by a great number of observers; even
Cruveilhier", who first described the disease, mentions them. In
literature, all grades of psychical disturbances are recorded, from an
abnormal tendency to write poetry (Valentiner"), to acute mania
(Lewis"), confused and excited states with hallucinations
127
(Redlich”), “paranoia persecutoria” (Bruns”) and “complete de-
mentia”. (Church and Peterson”). Most frequently, however, in-
tellectual defecit, and uncontrollable laughing and crying are men-
tioned. As to uncontrollable laughing and crying, Oppenheim has
stoutly maintained that these can not be interpreted as mental Symp-
toms, since they are not associated with sad or joyful moods.
Muller” in his admirable mongraph, while noting that 25 per cent of
the cases exhibited mental symptoms, states that psychical distur-
bances were not especially marked, and showed little that was char-
acteristic. Spiegel" contends that mental symptoms have no place
among the characteristic clinical symptoms of multiple Sclerosis.
While we do not claim to have read all of the contributions to
the literature of multiple sclerosis, we have perused a great number,
and with few exceptions, notably Raecke" and Redlich,” the psychi-
cal disturbances associated with the disease are lightly passed over.
The two cases reported in this paper and two other Westborough
cases mentioned above were committed to hospital primarily for
their mental condition. It is, perhaps, possible for a patient to suf-
fer a psychosis independent of a simultaneous affection of multiple
sclerosis, but we believe that the psychosis in Case II and the young
man mentioned above, perhaps, also, in Case I, is attributed in large
part, if not solely, to multiple sclerosis.
REFERENCES.
I. Dana : Discussion in New York Neuro. Soc. Jour. Nerv. and Ment.
Diseases, Vol XXIX, p. 288, 1902.
2. Spiller: A Report of Two Cases of Multiple Sclerosis with Necropsy:
With Remarks on Muscular Atrophy Secondary Degenerations, and
Loss of Tendon Reflexes, with Increased Muscular Tonicity, Occurring
in this Disease. Am. Jour. Med. Sciences, Vol. CXXV, p. 61. Igo3.
3. Spiller and Camp : Multiple Sclerosis, with a Report of Two Additional
Cases with Necropsy. Jour. Nerv. Ment. Disease, Vol. XXXI, p. 433.
I904.
4. Taylor: Multiple Sclerosis: A Contribution to its Clinical Course and
JPathological Anatomy. Jour. Nerv. Ment. Disease, Vol. XXXIII,
p. 361. I906. *
5. Redlich : Multiple Sclerosis. Die Deutsche Klinik. English transla-
tion under the General Editorial Supervision of Julius L. Salinger, M.D.
pp. 557-581. New York, 1911.
6. Taylor: 1. c.
7. Charcot: Lectures on the Pathological Anatomy of the Nervous System,
Diseases of the Spinal Cord. English Translation by Cornelius G.
Comegys, M.D., Cincinnati, 1881.
8. Redlich : 1. c.
9. Cruveilhier: Cited by Raecke, 1. c.
IO. Valentiner: Cited by Raecke.
II. Lewis: A Case of Disseminated cerebral Sclerosis. Jour. Ment. Science,
January, 1878.
I2. Redlich : 1. c.
13. Bruns: Zur Pathologie der disseminirten Sklerose. Berliner klin.
Wochenschr., 1888, p. 90.
14. Church and Peterson: Nervous and Mental Diseases. p. 465. Philadelphia,
IQO4.
I28
I5. Müller: Die multiple Sklerose des Gehirns und Rückenmarks. Jena,
I904.
I6. Spiegel: Ueber die psychischen Störungen bei der multiplen Sklerose.
Inaugural Dissertation, Berlin, 1891. Cited by Raecke, 16.
I7. Raecke: Psychische Störungen bei der multiplen Sklerose. Archiv f.
Psych, Bd. 4I, p. 482.
18. Redlich : 1. c.
EXPLANATION OF PLATES.
(XVII-XXVI)
FIG. I.-Illustrating sections from pons, cervical and thoracic levels of
Spinal cord, Case I. Myelin sheath stain. The cord lesions are sharply de-
limited; in the pons, some are clean cut, others diffuse. Zeiss series Ia.
FIG. 2.-Medulla and cord sections, Case II. Technical and photographic
details as in preceding legend.
FIG, 3–Upper portion of pons, Case II. Photographic details as in pons
section of Fig. I.
FIG. 4.—Coronal section taken just behind the anterior commissure and
passing through the optic chiasm. Note the sharply circumscribed degenera-
tion of fibres in the chiasm, stalk of infr. and supr. temporal gyri and
amygdal, and also of internal capsule, right. Photograph actual size. g
FIG. 5–Section passing through thalamus, middle commissure and pos-
terior portion of putamen. Note the degenerations around anterior horns
of lateral ventricles, in cornu Ammonis of each side and stalks of hippo-
campal gyri, antr. nucleus of thalamus and of blade of forceps of same
side, right. Photograph actual size.
FIG. 6.-Betz cell anterior central cortex, Case I. The cell is stained
after the Bielschowsky method for neurofibrils. Note dislocation of nucleus
to periphery, disappearance of the central neurofibrils with dark tinging of
interfibrillary substance in this region while the peripheral neurofibrils are
fairly well preserved. The illustration as here shown is the equivalent of
the central chromatolysis and axonal reaction of the Nissl stain which were
shown in this case. Zeiss 2 mm apochromat obj. projection oc. No. 2, bel-
lows extension 90 cm.
FIG. 7.—Small area of “insular sclerosis” in cortex of first frontal,
prefrontal area, left, Case II. Mann's stain after Weigert’s glia mordant
fixation. Note preservation of ganglion cells within the degenerated area
and the presence, particularly along the edges, of small round fairly clear
spaces. These are shown in the following figure to be cells of the so-called
Abraum type and most likely of glial origin. Bausch and Lomb 2-3 achro-
matic objective, no ocular, bellows extension IO5 cm.
FIG. 8.—The edge of such an area as described in preceding legend,
Case II, calcarine cortex, right. The patch, however, is older and consid-
erable glia fibre proliferation has taken place. The large cells, however, are
shown, and in the upper third of illustration, central portion, is seen a
ganglion cell against which a cell of similar nature is shown. Zeiss 8 mm
apochromat, projection ocular No. 4, bellows extension I22 cm.
FIG. 9.-Edge of fairly old lesion in spinal cord, lumbar region, of Case
I. Numerous large Abraumaellen between the glia fibres and within the
perivascular spaces. A few axiscylinders persist. Acid fuchsin–light green
stain after Alzheimer. Zeiss 2 mm. apochromat, comp. oc. No. 4, bellows
extension IO2.5 cm.
FIG. Io.—Perivascular spaces of a group of small vessels crowded with
Abraumgellen. Zeiss 2 mm. apochromat obj., projection oc. No. 2, bellows
extension I40 cm.
FIG. II.-An Abraum cell inclosing an amyloid body, centre of figure,
and beneath degenerating cells of the same character in which axiscylinders
can be made out. The last two figures from spinal cord of Case I. Zeiss
2 mm. apochromat obj. projection oc. No. 2, bellows extension 80 cm.
WEST BOROUGH STATE HOSPITAL PAPERs (series I) PLATE XVII.
:
º
-
-
-
-
º
-
-
Fig. I

WEST BOROUGH STATE HOSPITAL PAPERS (Series I) PLATE XVIII.

WESTBO ROUGH STATE HOSPITAL PAPERS (Series I) PLATE XIX.
FIG. 3

WESTBOROUGH STATE HOSPITAL PAPERS (Series I) PLATE XX.
FIG. 5

WESTBOROUGH STATE HOSPITAL PAPERS (Series I) PLATE XXI.
Fig. 6

WEST BOROUGH STATE HOSPITAL PAPERs (Series I) PLATE XXII.

WESTBO ROUGH STATE HOSPITAL PAPERS (Series I) PLATE XXIII.

WEST BOROUGH STATE HOSPITAL PAPERS (Series I) PLATE XXIV.


WEST BOROUGH STATE HOSPITAL PAPERS (Series I) PLATE XXV.
FIG. Io

WEST BOROUGH STATE HOSPITAL PAPERs (Series I) PLATE XXVI.

VII
SLEEP AND SOMNAMBULISM.
Authorized Translation by William W. Coles, M.D.
FROM THE FRENCH of PROF. H. BERNHEIM, NANCY, FRANCE.
To say that sleep is due to anaemia or hyperaemia of the
brain, to auto intoxication or to a simple cerebral dynamism gives
us but an incomplete explanation. All that we know clinically is
... that after a waking period of varying length a feeling of lassitude
comes over us, a sensation of somnolence; we go away by our-
selves, our eyelids become heavy; we remain quiet, relax; a pleas-
ant torpor envelopes us and external impressions gradually become
effaced. The voluntary intellectual activity is dormant while only
the automatic life of the imagination as expressed in dreams is
operative. After a varying length of time consciousness gradually
returns; external impressions become vaguely evident; we feel
again that agreeable torpor which formed the prelude to the
sleeping state; a sensation of somnolence which gradually passes
away ushers in the reawakening of the intellectual activity but
leaves a complete amnesia for the period of sleep except for the
recollection of certain dreams which may have passed along the
horizon of our consciousness. Only these sensations of somno-
lence preceding and following the sleeping state and the memory
of the dreams indicate to us that we have slept. The objective
symptoms are the closed eyes, the relaxed limbs, the apparent
unconsciousness of the subject and sometimes the deepened respi-
ration.
Still, these subjective and objective symptoms are not suf-
ficient to characterize physiological sleep. The intoxication due
to opium, chloral, uremia and acteonaemia of typhoid infection can
produce sleep; likewise hysterical or epileptic states. An apop-
lectic coma resembles a profound sleep but differs in that the
individual cannot be awakened. Catatonic stupor often gives the
impression of a prolonged sleep. However, anyone affected with
the above conditions may have a natural sleep which must be
differentiated from the pathological. The functional and organic
conditions of the brain must be widely different in the two types,
but the differences are unknown to us, for we know nothing of
sleep beyond its characteristic unconsciousness with or without
dreams. And these dreams, are they characteristic of sleep?
They may occur in the somnolent period preceding it or even
in the waking state as products of the imagination when the active
I3O
attention and reasoning power exercises no definite control over
these chance impressions. The condition known as reverie differs
little from the dream and our subsequent recollection of the con-
tent of the reverie may be vague or clear. -
We speak of partial sleep, of which reveries, autosuggestions
or suggestions due to hypnotic control in the waking subject are
characteristic phenomena and evidences of a numbing of cer-
tain psychic functions with activity of others essentially the imag-
inative. When we dream, sleep is really partial though still more
profound. But if the mere dulling of certain faculties is made a
criterion, the definition of sleep would include all abstractions of
the attention, whereas the word means for us a state of general
unconsciousness affecting the entire being and not a single organ
or psychic modality. Instead of referring to the reverie as a par-
tial sleep, it were better to consider the reverie as a waking
dream due to automatic cerebral activity uncontrolled by the vol-
untary attention. Either condition implies the persistence of the
consciousness, hence the most profound sleep, complete uncon-
Sciousness as in coma, is dreamless. Some believe that there is no
Such thing as a dreamless sleep, the memory preserving only
those dreams of a certain degree of intensity. But we know that
vivid dreams, even accompanied by somnambulism whether in the
natural or hypnotic sleep, may be entirely forgotten. Further-
more, we often awake from a few moments sleep recalling dreams
which have seemed to cover a long period of time, while on the
other hand we often wake after a night of profound sleep with the
memory of a dream which seems to have occupied but a moment.
Hence it seems as though the dream were merely an episode in
the sleeping state which has long intervals of absolute uncon-
sciousness.
Dreams may be either active or passive. In the latter the
sleeper watches the progress of the various episodes of the dream
as a mere spectator; in the former he lives out the life of the
dream and wakes convinced of its reality. He may even during
the dream be somnambulistic and walk about, talk or perform
many acts just as he would in the waking state. Can we say that
such a state of activity is really sleep? It is well-known that
hallucinability and somnambulism can be produced in the waking
subject.
This brings us to the study of the artificial or hypnotic sleep,
and will it shed any light on the physiological mechanism and
phenomena of natural sleep which are so difficult of explanation?
The rapidity with which the hypnotic sleep is induced imme-
diately speaks against its being due either to circulatory disturb-
ances or an intoxication, but rather to a simple cerebral dynamism
I31
without lesion which can be aroused by an idea alone. Circulatory
or toxic disturbances do not cause sleep itself but merely cause
a feeling of somnolence or torpor which suggest it.
While the hypnotic sleep and the natural are the same, we
know nothing of the psychology of either. Certain subjects in
whom an attempt is made to produce a hypnotic sleep have the
illusion of sleeping without any of its objective signs; they fol-
low any directions given them and yet believe that they are asleep
if they have been told that they are, and they even have an amnesia
for what has occurred in the period of sleep of this type. One
can even suggest that they have been asleep for several hours
before the commencement of the hypnosis and an amnesia for that
period will be developed. Other suggestible subjects fall into a
true sleep with all the objective symptoms. Commonly this
type has not been considered a true hypnotic state but a natural
state into which the subject permits himself to pass, since it is
characterized by the absence of catalepsy, anaesthesia, suggesti-
bility, etc., conditions which are commonly a sine qua non of the
varying degrees of intensity of hypnosis. But we believe that
these phenomena are neither functions of the induced sleep nor
the hypnotic state because they can be induced on the same sub-
jects in the waking state and are a function of their physiological
suggestibility. Hence we would say that the sleep in which these
hypnotic phenomena occur is the less profound because of the
persistence of the suggestibility. When the subject is made
really to sleep by suggestion, the brain is inert, but when cata-
lepsy or anaesthesia can be provoked the brain is active.
The term catalepsy implies commonly either hysteria or
hypnotism, but such a state may occur in many normal subjects
with the absence of either, subjects who are simply suggestible
and lacking to a certain degree in spontaneity. Persons who are
not suggestible often become so during severe illness, and this
suggestibility indicates that ideation persists, for in coma or a
typhoid stupor catalepsy can no longer be induced and there is
complete relaxation. The cataleptic state is a phenomenon of
consciousness, so with suggested analgesia, hallucinosis and all
the phenomena coming under the head of somnambulism, which
imply an active consciousness under the influence of suggestion,
and are not phenomena of sleep. To obtain them by suggestion
in the sleeping subject he must be at least partially awakened.
Hence, somnambulism is not provoked by sleep but by an
intensely active suggestibility; the brain must be awake. Certain
somnambulists have the appearance of being awake and say that
they are, others insist that they are asleep. Somnambulism can
be suggested during sleep only to be realized a certain time after
I32
waking, the so-called post-hypnotic suggestion. If this suggestion
deals only with the usual incidents of the daily life, the subject
would carry it out without realizing that his acts were under the
control of another. Cannot what results experimentally by the
Suggestion of another come about through auto-suggestion of
which the origin is unknown? Instead of suggesting acts, I could
Suggest post-hypnotic hallucinations, the hallucinatory form of
Somnambulism.
Somnambulism can be provoked by suggestion in the waking
state and the suggestion thus created, with or without hallucina-
tions, may last for a long time, constituting a true somnambulistic
life. When the subject is no longer dominated by the suggestion
he often has complete amnesia of what passed during the period.
This is especially likely to occur if the state of consciousness
has been profoundly modified, if the hallucinations or acts are
not in accord with his normal psychology. But, by suggestion,
the memories of this amnesic state can always be reawakened.
Induced Somnambulism, then, is only a state of consciousness in
which the subject actively realizes received suggestions.
Spontaneous Somnambulism occurs during sleep as an active
dream, manifesting itself by ideas, sensations, emotions or hallu-
cinations with active correlatives. A dream, reawakening im-
pressions of which the brain has a latent memory, gives the
suggestion. The student who during the night's sleep gets out
of bed, goes to his desk and writes or studies, then returns to
bed and in the morning believes that he has slept all night quietly,
is a somnambulist who, possessed by the idea of a duty to be per-
formed, is aroused from sleep to realize that idea in that special
state of consciousness or auto-suggestion followed by amnesia
which leaves his mind the illusion of unbroken sleep yet necessi-
tates a psychic and intellectual activity incompatable with true
sleep. -
Sometimes these somnambulisms reproduce themselves night
after night under the same form, and it is often easy to stop them
by suggestion. A divorced woman as the result of threats made
by her former husband suffered for months from nightly terrors
which she could not overcome. I put her to sleep by suggestion
and then by saying to her “There he is, who is there,” reproduced
the attack of somnambulism. Then by simply saying, “You will
have nothing to fear from him, you will see him no more,” I
dissipated the phantom and prevented her imagination from
bringing it up again. On awakening she had no memory of the
experience. It is almost always possible to get a good result
by persistent suggestive treatment, and this becomes especially
important when the somnambulism takes the form of, some act
of violence.
I33
Spontaneous somnambulism may occur without sleep in cer-
tain subjects as the result of a strong emotion which may cause
a profound psychic disturbance lessening the activity of the at-
tention and so modifying the consciousness as to induce the
Symptoms of Somnambulism. Religious ecstacy at times is re-
Sponsible for an hallucinatory somnambulism in which visual and
auditory hallucinations play a part. Hysteria, especially, induces
Somnambulism either during the convulsive crises, subsequent to
them or even in their absence, when the somnambulistic state
seems to replace the crisis.
The cause of the somnambulism is often unknown. Out of
the innumerable ideas passing through the mind one alone may
in an impressionable individual be retained by the brain and be
responsible for an active auto-suggestion. A dream, for example,
forgotten in the waking state, may by some association of ideas
give rise to a more or less lasting suggestion which will absorb
and direct the physical and psychic activity of the subject.
Before leaving the subject which I have elaborated further
elsewhere, I would add a word on the transformation of the per-
Sonality manifested in that form of somnambulism in which the
Subject, controlled by a certain sequence of ideas, may lose the
feeling of his own identity and believing himself another personal-
ity act in consequence. Other subjects without losing their identity,
without active hallucinations change only as to their character
or habits for a variable time and upon their return to the normal
consciousness have forgotten that they have passed through an
abnormal state. Such a state may be repeated periodically and
constitute the so-called double personality or consciousness of
which many examples have been cited in the literature. At first
glance, cases of this type seem strange and mysterious, contrast-
ing so strongly as they appear to with our physiological psychol-
ogy, yet, reflection shows that they have their analogues in
normal states so common that we pay no attention to them.
Under the influence of certain emotions or impressions there
may be an entire change in character; a person becomes angry,
for example, and does things which are entirely at variance with
his accustomed mental attitude. After a time his good nature
returns and sometimes he has no clear recollection of what he
did during the period of transformation. Certain women at
the time of the menstruation pass through such experiences. These
phenomena are not extraordinary and do not impress us nor
Yappear pathological unless they are followed by amnesia when we
believe that the subject has two lives, two personalities of which
the one is ignorant that the other exists.
But however remarkable this amnesia may be it does not
I34
imply any fundamental peculiarity of the period of modified con-
sciousness; it is not constant, it is not always complete. We have
seen that in the second state certain subjects preserve
a memory of the first condition, retain their sense of identity.
The experiences of experimental somnambulism are sometimes,
as with dreams, more or less clearly realized on the resumption
of the normal state and one can always, by suggestion, recall them.
Is it the same with the spontaneous double personality?
The reawakening of the memory is more difficult in the natural
than in the experimental Somnambulism because in the latter
we ourselves, by suggestion, have placed the mind in a state
of concentration which has created the images and it is easy to
reduplicate that state. But when the somnambulism is the re-
sult of special emotions provoked by hysteria, illness or certain
physical or moral shocks it is not always easy, by suggestion,
to reproduce an analogous state of consciousness which shall re-
call the same images, for the conditions responsible for the
phenomena must be reproduced, and that mere verbal suggestion
cannot always do. This same amnesia, more or less well marked,
is common as the result of emotional shocks, accidental or patho-
logical, which profoundly modify the consciousness. Following
typhoid fever the patient has sometimes forgotten what happened
in the early days of his illness or even before its onset, when the
consciousness was active and the intelligence clear. Certain
criminals who have perpetrated a crime, even with premeditation,
but with a brain over excited by their horrible conception, pre-
serve only a confused recollection of the drama in which they
have played a part, or else appear to have forgotten it entirely.
Hence, amnesia must be considered as a phenomenon, some-
times but not always, added to all serious psychological disturb-
ances. But whether amnesia is present or not, the modification
of consciousness which we term Somnambulism is the same, just
as the dream is the same whether or not it be followed by
amnesia. Between absolute amnesia and perfect recollection
all stages may occur, and this fact does not change the psychic
nature of the phenomenon. To show that the psychology of
somnambulism and the double personality, however singular and
abnormal it may appear, has its analogue in normal psychology,
and to separate from these phenomena the taint of the mysterious
and marvelous has been the constant aim of my studies.
CONCLUSIONS.
I. Profound sleep is characterized by complete suppression
of the psychic function of the brain occurring spontaneously as
a periodical, psychological process.
I35
2. Dreams are the result of the automatic activity of the
imagination uncontrolled by the faculty of judgment.
3. The dream presupposes that the brain is awake to some
degree, greater in the case of the active dream than of the passive.
4. Profound sleep produced by suggestion is accompanied
by unconsciousness with purely reflex reactions.
5. The so-called hypnotic phenomena, catalepsy, induced con-
tractures, analgesia, hallucinability and suggestibility demand a
reasoning activity implying the awakening of the mental faculties.
6. Active suggestion expressing itself by acts, thoughts or
hallucinations constitutes somnambulism which may be induced
in certain subjects either in the sleeping or waking states, and in
both states it may occur spontaneously as the result of emotional
shocks of hysterical or epileptic crises or of injuries.
7. The acts of somnambulism like all serious disturbances of
consciousness may be followed by a total or partial amnesia. In
the induced form of somnambulism the memory can always be
reawakened.
8. Somnambulism lasting for a considerable period of time
with or without hallucinosis constitutes a somnambulistic life
which if repeated often in the same subject alternating with fair
regularity with a period of normal life constitutes the so-called
phenomenon of double consciousness or double personality. Such
states without amnesia are natural to many individuals.
9. These different phenomena, dreams, somnambulism or the
double personality are not due to unconscious cerebral activity
but rather to a cerebral activity modified dynamically by sug-
\gestions or auto-suggestions which control the acts, thoughts
and feelings, indeed all the active mental life of the subject.
VIII
PURULENT STREPTO COCCIC CEREBRO_SPINAL MENINGITIS
FROM MIDDLE EAR DISEASE:
(PLATES XXVII-XXIX)
BY RUTH B. CoLES, M.D., AND SOLOMON. C. FULLER, M.D.
The opportunity to follow clinically the development, course
and termination of even an isolated case of purulent cerebro-spinal
meningitis, of streptococcic origin, and to compare with these
the autopsy findings, is not sufficiently common to detract from the
interest of the following case: *
W. S. H. (Dr. Coles) No. 929I, a woman thirty-six years of
age, was admitted to Westborough State Hospital, Dec. 3, 1910.
Family History.—The family history reveals a neurotic taint,
if not a direct heredity for mental disease. The mother of patient
was of a nervous temperament and suffered from heart disease.
Two near relatives (brother and paternal grandfather) died from
tuberculosis, one distant relative (paternal) was insane following
an accident when twenty. Otherwise the family history as elicited
is unimportant.
Previous History.—The patient herself was never rugged as a
child, although she had no serious illnesses. She showed a normal
mental development, and was a graduate of Wellesley College.
She was naturally a student and hard worker; normally social and
of attractive personality. She was married at the age of twenty-
six and had borne one child, now eight years old. There were no
complications noted with the labor, but during the lying-in period
the nurse reported that the patient appeared “queer” at times.
To everyone else she had seemed normal until two years ago, when
the mental trouble developed rapidly. She was, at first, excessively
“nervous” and worried over unimportant things. She did not
sleep or eat well, and complained of her head feeling badly. Hallu-
cinations of hearing soon developed with ideas of suspicion
against those about her; she was fretful and despondent, though
this last was not profound. She was later untidy, even filthy, but
not violent or especially resistive.
Here.—The patient was well nourished physically on admission
to Westborough, but the following abnormal conditions were
noted: heart’s action arythmical and accompanied with mitral
and aortic murmurs; tongue coated, bowels sluggish; the left pupil
larger than right, both reacting sluggishly to accommodation but
normally to light; hearing normal in right ear, markedly dull in
left. No other physical disturbances were detected.
138
Mentally, she presented the following picture: clear con-
sciousness, accurate orientation, good comprehension and attention,
flow of thought coherent and relevant, slight depression which
disappeared when talking of her early life, good memory
for events previous to the development of her psychosis but some
confusion as to more recent happenings, a tendency to evasiveness,
Some reticence and slight suspiciousness. There were also audito-
ry hallucinations and mild persecutory delusions based on hallu-
cinations which she termed “impressions”. There was a degree
of insight into her condition. She gave a satisfactory account of
her life and was able to give a reasonable cause for her break-
down—excessive work, extra responsibility and secret worry the
winter before. {
Throughout her hospital residence, her mental condition
showed little change up to Feb. 9th, 1911. She was always quiet
and lady-like, but reticent, of abnormally sober mien and difficult
to approach. She never made friends among the patients and was
always reserved towards the physicians and nurses. At times
she seemed puzzled, as though she did not understand what was
expected of her, and that which at first had seemed an inertia was
found later to be a slight negativism. She talked little about go-
ing home, but showed no indifference on this subject. She later
adapted herself more to her surroundings and occupied-her time
with sewing for herself and in reading. She was always retarded
in her movements and would frequently look the questioner in
the face a full minute or two before replying. She occasionally
showed an irritability, especially when the hallucinations which
were always present, became particularly active. The delusions
were of a mild persecutory type, based on her hallucinations.
Feb. 5, 1911. Her condition remained as stated above until
this date when she complained of earache, left ear. No other
symptom presented, and within 24 hours the trouble apparently
subsided.
Feb. 7, 1911. The left ear was found to be discharging a thick,
bloody serum. Some tenderness was noted over the mastoid, but she
no longer complained of pain and the next day the discharge ceased.
The tenderness was still present, though lessened. The mental con-
dition seemed as usual. -
Feb. 9, 1911. During the night of the 8th she became much
worse. This morning she was dull, stuporous, not responding
readily to stimuli, extremely restless, rolling the head from side
to side and moaning as though in pain. At times she seemed to
comprehend what was said, but would only reply “I don't know,”
to all questions. She did not obey directions readily. Tempera-
ture 105 F.; pulse 112. She lay with knees drawn up, but with-
I39
out rigidity of the muscles, distension or tenderness of the abdo-
men; urination frequent and involuntary. A well marked dermo-
graphia was present. Koenig's sign was absent. The pupils were
equal and reacted to light, accommodation test impossible. The pa-
tient seemed drowsy and frequently dropped into an uneasy
sleep from which it was difficult to arouse her. She seemed to
recognize her husband who came to visit her but made no effort
to speak to him, barely looking at him. Temperature varied
between IO3 and IO4 F.; pulse between 94 and I2O.
Feb. Io, Igſ I. Paracentesis.
Feb. I2, IQII. Lumbar puncture, but no fluid obtained.
. There was a well marked tendency to turn the head to the right
and backward but without rigidity of the neck muscles. Con-
sciousness was still more clouded. The patient moaned con-
stantly. The bowels were constipated.
Feb. I3, IQII. Rectal incontinence; abdomen distended but
not tense; difficulty in Swallowing. The patient has ceased to
moan, but moves her left hand continually, picking at the bed
clothing. The right arm is flaccid and occasionally twitching of the
right half of the upper lip is noted. Arm reflexes elicited, equal;
no abdominal reflex; knee jerks absent on both sides; plantar re-
flex normal on both sides; no ankle clonus; calcarea reflex absent;
little if any response to pain stimuli on legs. Attempts to flex legs
on thighs were difficult and caused evident discomfort to patient.
Congestion and edema of conjunctivae; left eye turned downward
and outward; pupils react normally to light; examination of discs
in possible because of position of eyes. There was a marked pul-
sation of the right carotid. Blood pressure I3O; marked leucocyto-
sis; temperature Ioff F.
Feb. I4, 1911. Death. &
Autopsy I7 hours post mortem. (Dr. Fuller.)
Anatomical Diagnosis.-Purulent cerebro-spinal meningitis,
cerebral congestion and edema, purulent otitis media, purulent mas-
toiditis, septic endocarditis, acute myocarditis; pulmonary hypos-
tasis; hepatic congestion and fatty degeneration; acute parenchy-
matous degeneration of spleen; congestion of pancreas; acute par-
enchymatous nephritis; congestion of internal reproductive
Organs, cystic Ovaries.
Abstract of Autopsy Protocol.—The calvarium is of normal
thickness but diploë are scant. The dura is normally adherent,
congested, tense and bulges laterally. On the left side, the vis-
ceral surface of the dura is smooth, but on the right side, a thin,
yellowish, fibrinous exudate is found beneath that part of the
membrane which covers the convexity of the right hemisphere,
I4O
and in the middle fossa of the base. This pseudo-membrane is
easily stripped. The pia is intensely congested and everywhere
the membrane exhibits a purulent, semi-gelatinous exudate, most
marked over the inferior two thirds of the mesial surfaces of the
frontal lobes—welding them together—the basal surface of the
frontal lobes, anterior and posterior perforated spaces, Sylvian
valeculae and ventral surface of pons. The exudate is also found on
the ventral surface of medulla, basal portion of cerebellum and in
the sella turcica, but here it is far less pronounced. In the exudate
are embedded the first, second, third, fourth, fifth, seventh and
eighth pairs of cranial nerves. The cerebral gyri are flattened and
edematous, the sulci shallow. The consistence of the whole brain
is diminished, the left tempero-sphenoidal lobe softer than the re-
maining portions. Scattered here and there over the convex,
mesial and basal surfaces of the cerebrum are numerous small
haemorrhagic areas on the surface of the cortex. Section of the left
tempero-sphenoidal lobe reveals on macroscopic evidence of abscess
ot the cortex or white substance, nor are such found in the cortex
beneath the most purulent areas of the pia. The cerebral arteries
are not sclerotic. The ependyma of the fourth ventricle is smooth.
. The hypophysis is dark red in color and mushy in consist-
ence. . . . . . The brain with pia attached and before sectioning
weighs I5O7.5 grams.
Section of middle and internal ears, and of the mastoids reveals
in the left middle ear and in the cells of the mastoid of the same side
a purulent exudate, while the corresponding structures on the right
side are negative for such findings.
Cord.—The cord is intensely congested, most marked in the
sacral region. Everywhere within the pia is a purulent exudate
such as described for the cerebrum, but less marked. Numerous
small osteomata, distributed chiefly over the ventral portions
of the thoracic and lumbar areas are also found in the pia. The
general consistence of the cord is diminished. No gross focal
areas of myelitis were encountered, though not every segment of
the cord was cut at autopsy. . . . . . . . . . .
Heart.—The pericardium is smooth and contains approxi-
mately 25 cc. of clear, straw colored fluid. The heart, though with-
in the normal range of size, is pale and flabby. . . On Section, one of
the mitral leaflets and the corpus albicans of an aortic semilunar
cusp (aortic surface) present each a soft, rough, grayish white vege-
tation elevated about 2 mm. above the Surrounding surface and
approx 3 mm. through the base. The remaining valves appear
normal. The heart muscle on section is pinkish yellow, streaked
with lighter areas and considerably diminished in consistence. . . .
Weight of heart, 40.5 grams.
I4I
For condition of remaining organs see anatomical diagnosis.
Bacteriological Earamination.—Smears from the pial exudate
and the pus content of mastoid cells, cultures from pial exudate on
glucose bouillon, agar and glycerine agar (8 tubes), pus from
mastoid (4 tubes), vegetation from mitral cusps (4). . . .All give
pure cultures of streptococcus.
Microscopical Examination.—In section stained with toluidin
blue, (FI and F2, prefrontal area, anterior central, superior parietal,
hippocampal gyri, cortex of calcarine area, base of cerebellum,
Optic commissure, frontal gyri of base), the most striking feature
is the enormous infiltration of the pia, over the summit as well
as in the sulci between gyri. (See Fig. 1). The funnel shaped
markings in the external periphery of the cortex (Pialtrichter Keys
and Retzius) are also infiltrated, but to a much less degree. With
higher magnifications the chief infiltrating cell is the polymorpho-
nuclear leucocyte. Still many lymphocytes are present and cer-
tain large cells—Macrophages—though fewer in number, are pres-
ent in all areas studied. The nuclei of these large cells are
vesicular, and are eccentrically disposed, though in younger forms
centrally located, their protoplasm stained a faint pink, coarsely
reticulated and frequently exhibiting inclusions of lymphocytes and
polymorpho-nuclear leucocytes, as many as five cell inclusions in a
single cell have been counted. (Fig. 2.) These cells, though fre-
quently found in the neighborhood of pial vessels and sometimes in
the vessel wall, are also seen in colonies some distance from vessels
and occasionally beneath the pia in the outer edge of the molecular
layer. Other large cells, more or less spindle shaped with a cen-
trally disposed darkly staining nucleus and deeper pink but more
homogeneous protoplasm, are also seen. Plasma and mast cells
fail in all the areas studied. Colonies of streptococci, in great
masses, are frequently seen. (Fig.3).
Lipoid substances as cellular content or free in pial mesh are not
seen in toluidin sections, but sections stained after Mooers-Min-
kowski method exhibit certain products of decomposition, rather
fine light red granules, in the protoplasm of the large spindle shaped
cells, in some endothelial and adventitial cells and also occasionally
free. These deposits, however, are not often encountered.
In the cortex, the vascular apparatus extending downward as
far as the outer layer of pyramidals, shows a very moderate infiltra-
tion, almost exclusively lymphocytic, but all of such vessels are not
infiltrated. There are also moderative progressive changes in
vessel walls, but no especially noticeable regressive alterations
shown. There is some cellular gliosis, particularly in the outer
laminae of the cortex, most marked in the molecular layer. An
increase of glia cells about small cortical vessels is also seen. The
I42
ganglion cells, rather generally present a shrunken, diffuse, dark
staining appearance, many showing rather tortuous apical den-
drites. Fuscous degeneration of ganglion cells in toluidin stained
Sections is not more excessive than is usually met with in the
brains of subjects of like age, nor is such noticeable in satellite
glia cells or other glia cells, but in the sections treated with
Mooers-Minkowski stain, fine red granules similar to those
described in the pia are found in practically every ganglion cell, in
many of the satellites, in endothelial and adventitial cells. In the
ganglion cells these granules are deposited not only in the area
where one usually finds the well-known yellow pigment but in other
portions of the cell as well, frequently in all visible dendrites.
Moreover, even when found in the area of usual pigmentation, in
glia as well as in ganglion cells, these granules do not occupy all of
the usual lipoid area. They probably are not the same granules
shown in Scharlach stained sections, for they are not as large or
a.S 1111111621 O11S.
In Sections previously fixed in Weigert’s glia mordant and
subsequently stained with Mann’s eosin-methylene blue mixture
or Mallory's phosphomolybdic-haematoxylin, the proliferation of
connective tissue fibers in the pia is better displayed, but the other
details of the pial exudate are not as well shown as by the other
methods described above. With regard to the deposits in gan-
glion cells shown by Mooers-Minkowski sections, there is no equiv-
alent of these granules in the Mann stained sections. Occasional-
ly, in the neighborhood of blood vessels and apparently free in
the diffuse glia mesh, a few dark-blue granules are encountered
which are not unlike the granules described by Alzheimer as
Fullkorperchen. A few small glia cells, with rather jagged pro-
toplasmic bodies containing similar though smaller granules, are
also seen in the molecular layer close to the pia, but these were
not encountered in all the sections. The haemorrhagic areas de-
scribed on surface of cerebrum in the protocol, appear to be the re-
sult of small haemorrhages within and beneath the pia.
The chief histopathological findings, then, with exception of
chronic nerve cell alterations, are confined to the pia. The very
moderate infiltration of vessels in the outer areas of the cortex
and—even there not universal—it seems to us may be discounted
as any very weighty evidence for an encephalitis. Infiltrative
phenomena are common enough in the brains of persons
dying of various psychoses and are not generally considered
as evidence of acute inflammatory reaction. The pial infiltration,
on the other hand, is replete with evidence as to explosiveness
rather than chronicity. The small haemorrhagic areas seen on the
outer surface of cerebral gyri, described in protocol, can likewise
I43
be ruled out as evidence of an haemorrhagic encephalitis; it seems
better to interpret them as extravasations from vessels in the pia,
for in the sections a thin layer of blood cells with a few macro-
phages was the only thing encountered microscopically at such
places. And yet from the intensity of the clinical symptoms and
-their rapid onset, more definite and acute changes in the brain
itself had been anticipated. It is possible that the extremely puru-
lent and turgid condition of the pia exerting pressure on the
brain may have been responsible in part for the clinical symptoms
after development of the meningitis, the streptococcic tox-
aemia serving as the remaining factor. Be that as it may, the chief
anatomical interest, it seems to us, lies in the fact that we have a
Severe purulent meningitis without cerebral histopathological al-
terations of sufficient intensity to be dignified by the designation
encephalitis.
EXPLANATION OF PLATES.
FIG. I.-Pia dipping down between two convolutions. The enormous
purulent infiltration is at once apparent and while there is some reaction in
the molecular layer, it is by no means commensurate. From the prefrontal
convexity, toluidin blue staining after Nissl, Bausch and Lomb 2-3 achro-
matic obj, no ocular, bellows extension IQ2 cm.
FIG. 2–Macrophages in the neighborhood of a small pial vessel, some
showing cell inclusions, others a coarse-meshed net structure of their pro-
toplasm. Some young forms are shown. Alcohol fixation, toluidin blue stain-
ing. Zeiss 8 mm apochromat, projection oc. No. 4, bellows extension 125 cm.
FIG. 3–Colonies of streptococci in the pial exudate. Alcohol fixation,
toluidin blue staining. Zeiss 2 mm apochromat, no ocular, bellows exten-
sion 187 cm.
WEST BOROUGH STATE HOSPITAL PAPERS (Series I)
PLATE XXVII.
|（~~~~ …
|-
|-
I
FIG.

WEST BOROUGH STATE HOSPITAL PAPERS (Series I)
PLATE XXVIII.
FIG. 2

WEST BOROUGH STATE HOSPITAL PAPERS (Series I) -- PLATE XXIX.
Fig. 3

* IX
BRAIN WEIGHTS AND PSYCHOSES
By STELLA. B. SHUTE, A.B.
Since there seems to be some general relation between psy-
choses and brain weights, 3OO brains of persons dying insane,
which came to autopsy at the Westborough State Hospital have
been examined and the cases grouped according to the various
clinical diagnoses in order to determine to what extent the present
material corroborates statistics thus far accumulated.
To decide the question whether a conclusion with regard
to the mental health of a person can be drawn & priori from the
brain at autopsy, it would be necessary to compare a table of patho-
logical brain weights with the corresponding normal weights and
thus strike an average in each group of psychoses.
The most complete investigation concerning normal average
brain weights which was worked out by Marchand, shows that
1400 grams is the average normal brain weight for men between
the ages of I5 and 60, and I275 grams for women. According
to the statistics of Marchand a brain weighing less than I250
grams is to be considered abnormally small and One weighing
over 1550 grams abnormally large. The lowest weight of a female
brain which was not pathological was that of a woman over 60
years of age, the weight being 950 grams. With the exception
of this case, Marchand's lowest boundary among female brains
was IOOO grams.
Handmann, of the Pathological Institute at Leipzig, ex-
amined 1414 brains and obtained results similar to those of Mar-
chand, namely, I370 grams the average for men, I250 grams for
WOII le11.
The researches of Tigges and others show that with psychoses
in general, and dementia paralytica in particular, the brain weight
diminishes in proportion to the duration of the disease, while in
acute progressive psychoses frequently a high brain weight is
found.
Mittenzweig compared the brains of II32 patients dying in the
Herzberg Institution with Marchand’s normal weight paralytica,
and separated them according to four groups: dementia paralytica,
senile dementia, organic and functional psychoses. He found that
the average brain weights in dementia paralytica and senile de-
mentia cases were considerably lower than the corresponding
normal weights, with women even as low as the normal minimal
I46
weight. With the other organic and functional psychoses there
was no appreciable difference from the normal. A number of
paralytic and senile brains had a weight which was below the low-
est normal boundary (IOOO grams for men, 950 grams for women
Over 60 years). With such brains as showed “absolutely low”
weights, a mental illness, according to Mittenzweig, was very ap-
parent. The conclusions from the painstaking work of Mitten-
zweig are, that in general the brain weights with psychoses are
lower than the normal weights and that brains with Organic dis-
eases may be considerably lighter than the lowest normal brain
weight. .
Bolton in his extensive treatise on “Amentia and Dementia,”
found that in all of his various groups of psychoses the average
brain weights were below the normal averages of Marchand.
In 1907 Entres pointed out that in many cases with short
duration of hemiplegia a high brain weight is determined, es-
pecially in cases where the shock is followed by death, whiie
in cases of long duration of illness, Ilberg and Babcock have both
shown that with long-standing paralysis a loss of weight propor-
tional to the length of the supervening psychosis is the rule.
The recent study of Scharpff includes the four groups of psy-
choses into which Mittenzweig classified his material, although his
tables, patterned after the Ziehen method, are based only on de-
mentia paralytica and senile dementia cases. As a whole, his
averages agree with those of Mittenzweig. Of his dementia
paralytica group, however, the average weight was higher than
the corresponding weight of Mittenzweig's group, but he ex-
plained that difference by the fact that in an asylum where there
has been time for atrophy, more long-standing cases come to
autopsy than in a clinic where relatively more acute progressive
cases are observed.
The present material includes the following psychoses:
dementia paralytica, senile dementia, organic dementia (including
arteriosclerosis and tumors), paranoia, epilepsy, dementia praecox,
involution melancholia, manic depressive insanity, alcoholism,
imbecility, exhaustion-infection psychosis and syphilis.
IDEMENTIA PARALYTICA.
The 60 cases of dementia paralytica are grouped according to
the duration of the psychoses”, into three sub-classes: those less
than one year, including 13 male brains with an average age of
43 years, and average brain weight of 1381.9 grams; those from
*For the duration of the psychoses the time in hospital is given plus the assigned dura-
tion before commitment. The latter, in many cases, is only approximate, since the histories
given by relatives of patients are not always dependable.
I47
one to three years, including twenty-five male brains with an
avérage age of 49 years and an average brain weight of I242.2
grams, and three female brains with an average age of 41 years
and an average brain weight of I2OO. I grams; and those with a
psychosis for more than three years, including fifteen male brains
with an average age of 45 years and an average brain weight of
I230.3 grams, and four females, with an average age of 45 years
and an average brain weight of IIO3.6 grams. -
The lowest brain weight was 963.9 grams, with a psychosis of
more than three years, lower than the minimum weight for normal
brains but 53.9 grams more than Scharpff's lowest male general
paretic brain. Ten of the sixty brains, six males in the first group,
two in the second, one in the third, and one female in the second,
were above the normal average weight (1400g.).
SENILE DEMENTIA.
Of the male senile dementia brains with a psychosis for less
than a year there are seventeen cases with an average age of
73 years and an average weight of I263.6 grams; seventeen cases
with a psychosis from one to three years, with an average age of
73 years and average brain weight of I258.9 grams, and sixteen
cases of more than three years with an average age of 74 years
and an average brain weight of I225.6 grams.
Of the female senile dementia brains there are six in the first
period with an average age of 71 years and an average brain weight
of 1179.3 grams; and thirteen in the third period with an average
age of 77 years and an average brain weight of IIII.2 grams.
The lowest senile dementia brain weight was 882. I grams, a
female 85 years of age, which is lower than the lowest normal
weight reported by Marchand as 950 grams, but higher than
Scharpff's lowest female senile brain (776 grams). Scharpff
pointed out that the average senile dementia brain weights for
both sexes are relatively lower than the average dementia para-
lytica brain weights. Taken as a whole, this series of fifty senile de-
mentia brains weighs only 38.8 grams less than 53 general paretic
brains.
McGaffin, in his “Analysis of Seventy Cases of Senile Demen-
tia”, states, “it would seem that the female brain tends to lose in
weight under the action of senile changes more commonly than the
male and that the loss is greater.” Southard also, in his “Senile
Dementia” paper, has more female brains under weight than male.
Both McGaffin and Southard, however, considered 1358 g. the nor-
mal average brain weight for men and I235 g. for women. Even
with these figures instead of Marchand's, the male weights are rela-
tively less in these fifty cases than the female.
I48
ORGANIC IDEMENTIA.
In the first period there are seventeen male brains with an
average age of 61 years and an average weight of I314.8 grams;
thirteen male brains in the second, with an average age of 66 years
and an average weight of I2O2.7 grams, and in the third period, ele-
ven with an average age of 64 years and an average weight of
I235.2 grams. The female brains with organic dementia include
three in the first period with an average age of 70 years and an
average weight of IO67.8 grams; six in the second period with
an average age of 53 years and an average weight of I230.8
grams, and two with a psychosis for more than three years with
an average age of 66 years and an average weight of IOQ4.9 grams.
The fifty-two organic dementia cases include seventeen brains
with arteriosclerotic focal lesions, and six brains with tumors.
Fourteen male arteriosclerotic brains had an average weight of
I282.2 grams. Five of the brains with tumors, three females, two
males, were below the normal average weight, the other, a female,
weighed 1275.7 grams. In this group it is evident from the figures
that the weights of the organic dementia brains, particularly the
arteriosclerotic, are in inverse ratio to the age and length of
psychoses.
PARANOIA AND CONDITIONS AKIN TO PARANOIA.
Ten female brains with a psychosis for a period of more
than three years with an average age of 44 years, have an average
weight of I2O6 grams. Two male brains with a psychosis for two
years and four years respectively, and 64 and 66 years of age,
have an average weight of 1396.2 grams.
EPILEPSY.
Seven female epileptics with a psychosis for less than three
years, with an average age of 43 years, have an average brain
weight of 1211.9 grams. Six male epileptics with a psychosis for
less than three years with an average age of 44 years have an aver-
age brain weight of I335.9 grams.
DEMENTIA PRAECOX.
Six female dementia praecox brains with a psychosis for less
than three years with an average age of 34 years have an average
weight of 1308.6 grams, which is above the normal average female
weight (1275g.). . Two female brains with a psychosis for five years
and seven years respectively and 34 and 44 years of age, have an
average weight of 1332.4 grams. Five male dementia praecox
brains with a psychosis for more than three years and an average
age of 48 years have an average weight of 1461.4 grams, which is
I49 /
61.4 grams above Marchand’s normal average. Three brains
with a psychosis for less than three years and an average age of
37 years have an average weight of 1481.2 grams.
IMB ECILITY.
Of eight male brains five were below the average normal
weight, while one weighed 1729 grams and another 878.8 grams.
Of five female brains the average weight was 12II.9 grams.
INVOLUTION MELANCHOLIA.
Eight male brains with a psychosis for less than three years
and an average age of 51 years have an average weight of I374
grams. One brain with a psychosis for four years and 60 years of
age, weighed I424.5 grams.
MANIC DEPRESSIVE INSANITY.
Three male brains with a psychosis of less than three years'
duration, with an average age of 44 years, have an average weight
of 1360.7 grams. Three female brains with a psychosis for less
than three years, with an average age of 48 years, have an average
weight of I.332.3 grams. One male brain with a psychosis for
four years and aged 55 years, weighed I282.8 grams.
ALCOHOLISM.
Five male brains with psychoses for less than three years,
and an average age of 52 years have an average brain weight of
1376.3 grams. Two male brains with more than three years' psy-
choses, with an average age of 58 years, have an average weight
of I21 I.9 grams. Three female brains with psychoses of less than
three years’ duration have an average age of 50 years, and an aver-
age weight of I.254.4 grams. Two female brains of more than three
years' psychoses, with an average age of 45 years, have an average
weight of I.247.3 grams.
EXPHAUSTION-INFECTION PSYCHOSIS.
Seven female brains with psychoses for less than three years,
and an average age of 44 years, weigh on an average of 1234.8
grams. Seven male brains of less than three years' psychoses,
with an average age of 48 years, have an average weight of 1297.9
grams.
SYPHILIS.
Three female brains with psychoses for less than three years,
with an average age of 49 years, have an average brain weight of
II 76.5 grams. One male brain, with a psychosis of short duration,
aged 35 years, weighed I396.2 grams.
Of the last seven groups of cases, with the exception of the
dementia praecox brains, the general conclusions of Mittenzweig
| I5O
are borne out, viz., brain weights with psychoses are lower than
normal weights and brains with organic focal lesions may be con-
siderably lighter than the lowest normal brain weight. But in all
estimations and comparisons of brain weights a very important
factor must be taken into consideration, namely; the ratio of brain
weight to skull capacity. A brain might be quite small for one
subject, and yet a similar weight would be large enough for
another. At Westborough, skull capacity is now also estimated,
but the cases are as yet too few from which to draw definite con-
clusions as to the diminution of brain weights in persons dying
insane. In most of the cases, especially senile atrophic brains,
where the brain did not fall far below the average normal weight,
there is sufficient disparity between the skull capacity and brain
weight to suggest the importance of the relation of skull capacity
to brain weights.
REFERENCES.
Bolton : Amentia and Dementia. Jour. of Mental Science, July, IQ05.
Babcock: Progressive Loss of Brain Weight. Philadelphia Med. Jour. I.
No. 25. I898. &
Entres: Hirngewichtsverhältnisse bei progressiver Paralyse. Inaug.-Diss.
Wurzburg IQ07.
Handiº giºvisite des Menschen. Arch. f. Anat, u. Physiol. Anat.
bt. 4. S. I. *
Ilberg: Gewicht von Paralytikerhirnen. Allgem. Zeitschr. f. Psych. Bd. 60
Heft 3. IQ03.
Marchand: Ueber das Hirngewicht des Menschen. 27 BC. Abt. d. math.-phys.
Elasse d. Kgl. Sachs. Gesellschaft d. Wissenschaften.
McGaffin: , Am. Jour. Insan, Vol. 66, p. 649. I9IO.
Mittenzweig: Hirngewicht u. Geisteskrankheit. Zeitschr. f. Psych. Bd. 62.
I905.
Scharpff s Hirngewicht und Psychose. Arch. f. Psych. Bö. 49. Heft I. S. 242.
I9I2.
Southard: Am. Jour. Insan, Vol. 66, p. 673. I910. . *
Tigges: Gewicht des Gehirns und seiner Teile bei Geisteskrankheiten. Allg.
Zeitschr. f. Psych. I889. Bol. 45.
X
A REPORT ON THE THERAPEUTIC USE OF BACTERIAL
V ACCINES AND ON ANTI-TYPHOID VACCINATION
AT WHESTBOROUGH STATE HOSPITAL.
BY CLARENCE C. BURLINGAME, M.D.
For a short time, and that not a long while ago, bacterial
vaccines held first place in the medical journals, but they have been
already forgotten or abandoned by many. There are those, how-
ever, who still believe that bacterial vaccinations deserve a place
among the established practices of medicine, even though they
have failed as a panacea for all of the bacterial diseases. Those
who have employed the vaccines most extensively have come to
believe that they are reliable agents in combating certain infec-
tions, and that in them is found a valuable adjuvant in the hand-
ling of many surgical conditions. To one working among the in-
Sane, the vaccines come as a great boon, for it is not only difficult,
but at times impossible to carry out usual Surgical treatments suc-
cessfully. A simple method of raising the body resistance against
bacterial invasions and thus materially shortening the course of
the infection or preventing its recurrence—such as has been
demonstrated in many of the cases on which this report is based—
should, therefore, be welcomed, and more extended study given
the subject to determine the conditions under which vaccine
therapy may be employed to the best advantage. *
The period covered by this report extends from May, 1909,
to April, 1912. During this time vaccine therapy has become more
and more a part of the routine practice of the hospital in dealing
with bacterial infections. The cases treated with vaccines include
not only patients of this hospital, but also employees and a group
of cases from the Lyman School for Boys, a State reform school
in the town of Westborough.
Most of the vaccines used were prepared at the hospital
laboratory. In the beginning of the work stock vaccines were
secured elsewhere. In many instances autogenous preparations
were used exclusively, but more frequently Westborough Hospital
stock vaccines preserved from preceding cases were employed.
The results of our stock vaccines were usually good, particularly
where a stapylococcus was the Offending organism. While in most
instances with infections of this character the Stock vaccines were
entirely satisfactory, cases did occur which, though responding to
the stock, showed a tendency to relapse, remaining well only after
administration of an autogenous vaccine.
I52
Method of Preparation.—Cultures were taken in the usual man-
ner and the vaccine prepared from the growth resulting from the
Second implantation when the delay in treatment warranted, other-
wise the vaccine was prepared from the first culture. The cultures
Were made on plain agar Slants, except as stated otherwise later
on in this paper. After 18 to 24 hours incubation, and the mor-
phology of the organisms determined, 5 cc. of sterile normal saline
Solution were added and then by means of a finely pointed pipette
the growth was washed from the slant without breaking the sur-
face of the medium. The 5 cc. of bacterial emulsion thus obtained
was transferred to a 30 cc. sterile test tube, the number per cc.
of the emulsion estimated in one of two ways. The procedure
with One of the methods was to mix thoroughly equal parts of
the bacterial emulsion, human blood and a solution of sodium
citrate and spread evenly on slides. After the slides were dried
and Stained, a comparative count of bacteria and erythrocytes in
Several fields was made. Good counting was facilitated by mark-
ing the eye piece of the microscope in quadrants. The number of
red blood cells in a cmm. being an approximately known quantity,
the ratio of erythrocytes and bacteria was used to compute the
number of bacteria per cmm. of the emulsion. The other method
made use of a Zeiss counting apparatus, proceeding as in the count-
ing of blood cells. After determination of the density of the
emulsion sufficient sterile normal saline solution was added to
bring about the desired number of bacteria per cc., the whole
thoroughly emulsified in the 30 cc. tube by means of a finely
pointed pipette with a rubber bulb on one end.
One of the workers in the laboratory rightfully considered the
standardization of vaccines as only approximately correct at best,
and so abandoned the more laborious methods just described and
adopted a simpler method which was time saving. Experience
had taught him that a certain degree of Opalescence in his
vaccine represented approximately 500,000 bacteria with a cer-
tain organism. Having obtained this opalescence by adding
to sterile normal saline solution portions of the original bacterial
emulsion, the vaccine could be further diluted to any desired
strength by the addition of proper amounts of sterile salt, solu-
tion. All things considered, this method of standardization does
not seem entirely without merit, and it probably comes as near
telling us what the strength of our vaccine is as do any of the others
in common use. After all, it must be admitted that the number
of bacteria in a given quantity of emulsion does not always de-
termine the therapeutic activity of the vaccine. The individual
strains of an organism may vary widely, and it is by clinical tests
alone that we are able to gauge with any degree of accuracy
I53
the activity of a vaccine. Moreover, the same vaccine used for
two persons often may result in reactions of very different in-
tensity. A conservative therapeutic procedure, then, would be to
make the initial dose small enough to be within the bounds of
Safety, and grade subsequent injections in proportion to the in-
tensity of the reaction. *
Three methods of sterilization have been used in our work:
heat alone, chemicals alone and heat and chemicals in combina-
tion. We have had no unfortunate clinical results with vaccines
sterilized in any one of these ways. The combined method of
sterilization has been equally active and produced just as good
results as the other two methods of sterilization. The combined
method renders the vaccine doubly safe, and, since it does not
seem to affect the activity of the vaccine, is to be recommended.
Vaccines sterilized by heat alone may subsequently become in-
oculated, as happened several times in our work, even though the
clinician using the product had used reasonable care in withdraw-
ing from the container sufficient amounts for injection.
The combined method of sterilization was produced as fol-
lows: after the desired dilution of the original emulsion had been
obtained, a sufficient amount was drawn off to bring the remainder
down to the I5 cc. mark on the test tube. One drop of pure lysol
or carbolic acid was added and thoroughly mixed by means of a
pipette. The open end of the tube was then closed with a sterile
rubber cap which was punctured with a fine needle in order to
permit the escape of expanded air when the tube was heated.
The sealed tube was then suspended in a water bath maintained
at a temperature from 58 to 60 C. for one hour. This was always
found to be sufficient to kill all bacteria. The sterility of the
product was always insured by puncturing the rubber diaphragm
with a sterile needle and withdrawing I-2 cc. of the newly made
vaccine, a part of this planted on agar and the remainder in
bouillon. If after 18 to 24 hours of incubation no growth oc-
curred the product was considered safe for administration. The
vaccine was either kept in the large tube or transferred to small
amber colored bottles, previously sterilized with rubber caps over
the mouth, the vaccine injected through the rubber caps.
Slight departure from the methods of preparation just out-
lined was made with some of the streptococcus vaccines, especially
where it seemed necessary to prepare the product speedily. The
original culture was made in bouillon and incubated for twelve
hours. The bouillon was then centrifugalized in sterile tubes
for five minutes at high speed. Following this the Supernatant
fluid was drawn off with a finely pointed pipette. The residue
was emulsified with distilled water and again centrifugalized for
I54
five minutes and the supernatant fluid drawn off, leaving a residue
of washed streptococci which were then emulsified with sterile
normal Saline solution and standardized by one of the methods
already mentioned. A vaccine obtained in this manner was almost
exclusively streptococcic, even when the culture was from an in-
fection contaminated with a staphylococcus. In clinical use it
proved quite as effective as streptococcus or mixed streptococcus
and staphylococcus vaccines prepared by the usual methods.
Staphylococcus—The staphylococcus vaccine has so far proved
to be the most reliable, and was the most extensively used. In
the cases here reported, doses of from IOO,000,000 to 400,000,-
OOO were employed in general furunculosis, simple furuncles,
Septic infection, carbuncle, acne and abscesses. Of the cases of
furunculosis, a large number came from the Lyman School for
Boys, among which were not a few refractory cases which had
resisted other forms of therapy for a long period. With one ex-
ception, these boys received no other treatment, nor was the diet
or mode of life readjusted. This gave an exceptional opportunity.
for estimating the value of the treatment, since any benefit follow-
ing could reasonably be considered as due to the vaccine and not
merely coincident. Twenty-one of these boys treated for furun-
culosis showed improvement after the administration of vaccines.
Forty-nine cases of furunculosis were treated, a total of 174 in-
jections given with an average of 3.55 treatments required to effect
a cure. No case failed to be relieved entirely, although in one case
it was not until after the third autogenous vaccine had been made,
the dose carried to 400,000,000 and repeated every third day did
the very severe furunculosis yield. This case was also com-
plicated by pustular acne.
A very severe case was No. 7768, a very poorly nourished,
untidy, resistive, suicidal and violent case of dementia praecox.
For six weeks he had suffered from crops of boils, and for fully
five months had had single furuncles one after another. After
opening these boils, efforts to keep dressings in place were flat
failures, even when in mechanical restraint, because of his dexterity
in freeing himself and his continual restlessness. After the third
injection of a stock staphylococcus vaccine no new lesions ap-
peared, and in three weeks there was complete recovery. Only
persons who have to handle cases of this character in an excited
katatonic can fully appreciate the comfort this brought to patient
and physician. This man continued his untidy habits, but up to the
time he was transferred to another hospital did not develop any
further boils. *
Where time is a consideration in the preparation of an auto-
genous vaccine, and the staphylococcus determined it is good
I55
practice, as repeatedly demonstrated in our work, to inject a mixed
Staphylococcus (albus, aureus and citreus) vaccine in every case
of boils, beginning with IOO,OOO,OOO to 200,000,000 bacteria, re-
peating every third or fourth day and gradually increasing the dose
until cure is effected. A rebellious case, however, will now and
then require an autogenous vaccine, but in practice these were
found to be few.
Four cases of septic infection due to staphylococcus were
treated. All of these cases had severe local manifestations as
well as pronounced constitutional symptoms which were serious
enough to endanger the limb if not the life of the patient. Vaccines
were used in conjunction with usual surgical treatment, with the
result that improvement was more rapid than is usually expected
in cases treated without vaccines.
Three cases of severe bone infection were treated with stock
vaccines without result, but after the administration of autogenous
vaccines two of them made good recoveries, while the third died
following amputation of a forearm. This was the case of an
elderly man who in addition to a chronic alcoholic psychosis was in
very poor physical condition generally. The case did not do well
from the first, and not until the process was well advanced was
the vaccine employed. It is also quite probable that the offending
Organism was not cultivated. There was some reaction from a
Stock streptococcus, although no Streptococcus was found on the
cultures made.
Four cases of carbuncle were treated with an average of five
injections per patient. The results were quite as good as with cases
of furunculosis. Here, again, the vaccines proved of great as-
sistance in handling a surgical condition in disturbed and violent
insane persons. Two of these cases constantly disturbed the dress-
ings and would coöperate in no way with the efforts at treatment.
One of the cases made a very prompt recovery in spite of the
fact that he rubbed filth into his wound at every opportunity.
The combined staphylococcus was employed. Active surgical
treatment was also kept up.
Four cases of abscess due to staphylococcus received on an
average 2.5 injections per patient and with surgical measures
carried on simultaneously prompt healing ensued. One of these
cases was a long-standing abscess of the breast which had resisted
all other efforts at treatment.
During the period covered by this report two typical cases
of acne vulgaris were treated with staphylococcus vaccine. One of
them did not respond at all, even to large doses, and the second
only after the administration of nuclein. Acne bacillus vaccine was
not used in either case, but subsequent experience has made it
I56
Seem worth while to give the acne bacillus vaccine a thorough
trial before abandoning vaccine therapy for this condition.
Streptococcus-One example of the use of streptococcus
vaccine in Septicemia, of more than ordinary interest to the writer,
was in his own person. The streptococcus had been demonstrated
in the circulation, so the diagnosis was positive. The vaccine
furnished very prompt relief from pain and all other symptoms. A
Second case resulted equally fortunately. In this latter case the
Organism was not demonstrated in the circulation, but was found
in the pus. The doses used in these cases varied from 5,000,000
to I5,OOO,OOO bacteria.
A stock Streptococcus vaccine was tried in the treatment of
erysipelas, but with little or no effect. An autogenous vaccine
from a case of erysipelas was employed with apparently good ef-
fect, and this was subsequently used as an erysipelas stock vaccine,
also with apparently good results. It is more or less difficult to
determine the exact value of a vaccine in a disease like erysipelas
which is seldom fatal, and especially where other treatment is em-
ployed simultaneously. Temperatures often drop suddenly in
erysipelas under the ordinary methods of treatment, and, more-
Over, the symptoms of this disease are frequently not severe.
Nevertheless, the prompt results in seven cases of erysipelas
treated with vaccines led to the belief that this method of treat-
ment was of value. In all cases the temperature fell noticeably
after the injection of vaccine, and in the cases where a subsequent
rise occurred a second injection promptly lowered the temperature.
Colon Bacillus-Three cases were treated with colon bacillus
vaccine, all of cystitis, receiving a total of twenty-one injections.
The results, while not wholly satisfactory, were not entirely with-
out benefit. The few cases, and the short time which they were
under treatment, do not permit positive conclusions. Only one
of the cases showed any marked improvement in the urine. In
one case the quantity of urine gradually diminished during treat-
ment, gradually returning to the normal amount when the vaccines
were discontinued.
Gonococcus.-Among hospital patients gonococcus vaccine was
used but little and only in cases of chronic urethritis. These cases
made gradual but good recoveries, receiving at the same time local
treatment. In acute cases treated outside of the hospital vaccines
did not seem to materially shorten the course of the disease, but
there was an absence of sequelae, even in instances where patients
used poor judgment and were not always abstemious in the active
Stage.
Pneumococcus.-In our work pneumococcus vaccine has not
yielded good results in pneumonitis. But this may be due to the
I57
fact that without exception it was employed in combating the
terminal pneumonia of bedridden patients. In every case, how-
ever, the vaccine produced a sudden fall of temperature without
marked lowering of the pulse, soon followed by a rise in tem-
perature. All other symptoms were unaltered.
TYPHOID VACCINE FOR THERAPEUTIC USE AND ANTI-TYPHOID
V ACCINATION.
The use of typhoid bacillus vaccine in the treatment of typhoid
fever was not sufficiently employed at the hospital to draw definite
conclusions as to its value; but a relapse in one case
treated at the hospital seemed controlled by doses of 50,000,000
bacteria every fourth day, the patient making a good recovery.
Anti-typhoid vaccination was undertaken on the recommenda-
tion of the Massachusetts State Board of Health and was given
to employees of the hospital who voluntarily submitted themselves.
It was a new thing, and although subsequent good results aided
in getting converts, at first but few seemed inclined to avail them-
selves of the opportunity to become immunized. Many were pre-
pared for almost every imaginable symptom, and indeed every-
thing from true elevation of temperature to sensations as though
bugs were crawling over the scalp was reported.
Immunization was accomplished by four injections given five
days apart, although inability of the subject to appear sometimes
lengthened the period to a week between inoculations. The first
dose was always 50,000,000 bacteria, the second IOO,OOO,OOO, the
third 200,000,000 and the final dose 400,000,000. In all cases the
insertion of the deltoid was selected as the site of the subcutaneous
injection, sometimes alternating from right to left, although in
most cases the reaction from the preceding dose had entirely dis-
appeared and the subject preferred the same arm. No case carry-
ing a mouth temperature IOO degrees F. or Over was given an in-
jection. The hour of 4 P. M. was selected for the vaccination clinic
in order to detect afternoon rise of temperature, if any existed.
No woman was given the first dose during menstruation, although
this was not allowed to interfere with subsequent injections where
no ill results were observed. The temperature was taken in each
case before the injection of vaccine and again four to six hours
after. A card index of all symptoms was kept, together with
names, ages and occupations of subjects.
A total of one hundred and three persons were given the first
dose, ninety took the second injection, four leaving the employ of
the hospital, and nine refusing further injections. This refusal was
evidently due to an hysterical attack in the thirty-eighth patient
vaccinated. Although the patient was completely herself after
158
being talked to for a few minutes by the physician, the nine per-
Sons refusing seemed to believe that the vaccine was entirely
chargeable with the attack. None of the nine reported any severe
Symptoms in themselves. Eighty-seven received the third in-
jection, one leaving the hospital between the second and third.
Eighty-three took the full four injections; again one left the
hospital between injections.
Of a total of one hundred and three who started to take the
vaccinations, seventeen from choice did not take the full four in-
jections. Practically all of these failures were among the first
to submit themselves when the procedure was looked upon with
Suspicion and misgivings. {
The following table shows the temperature registrations after
each injection:
Between Between Between Between Under
Inoculation IO3. & IO2. & IOI. & IOO. & 99.
IO2. IOI. IOO. 99.
First O O 7 29 67
Second 2 O I IQ 68
Third I O O 7 79
Fourth O I I 2 79
With one exception the elevation of temperature was not as-
Sociated with especially marked local or constitutional symptoms.
One case had a temperature of IO2.2 after the second, and again
after the third injection, but had it not been for the thermometer
he would not have suspected the rise. He was especially free from
constitutional symptoms and had a very moderate local reaction.
The temperature was normal in twelve hours.
Nineteen cases only reported headache after injection. Some
reported it only after the first, some after the first and second,
and two after each of the four doses. The first injection most
often produced the headache. Slight nausea was reported in but
one case. Bad dreams were reported by two after each injection,
and difficulty in remembering things the next day was reported
by three after their third and fourth injections. These symptoms
are given without regard for their value as pointing to possible
results of anti-typhoid vaccination. Only twenty-six inoculations
out of a total of three hundred and sixty-three had severe enough
local reaction to produce redness or swelling extending to the
elbow, but in all cases the objective symptoms were out of pro-
portion to the subjective, being much less pronounced. All local
reaction subsided promptly. Aching after one or the other in-
jections was the most constant symptom, although it seldom oc-
curred twice and was not severe.
In one case, what might be characterized as a severe reaction
I59
occurred. Two days after the second injection he developed
symptoms of influenza, which disappeared before the next dose.
After the third injection he developed severe rhinitis, with puffiness
of the eye lids, herpes about the lips, general feeling of malaise
and lassitude. He remained in bed for two days and was then
himself again. He returned for the final dose but suffered no
severe reaction.
Summing up, then, the symptoms which may be expected after
anti-typhoid vaccination are much less severe and far more tran-
sitory than those which may be commonly looked for after small-
pox vaccination. The vast majority of cases have a little stiffness
and soreness of the arm with slight, if any, headache, and are able to
continue their employment without interruption. There is not
the chance for infection of the arm, so dreaded in smallpox vac-
cination.
In an institution for the insane, where protection against
typhoid fever is equally to be desired as protection against small-
pox, which seldom occurs, anti-typhoid vaccination seems a
measure worth while, since typhoid fever is not a rare disease
among patients and nurses in hospitals of this character, although
not as common as in general hospitals.
&
XI
MULTIPLE PAPILLOMA OF THE BRAIN
(ADENO CARCINOMA)
(PLATES xxx-xxxII.)
BY SOLOMON. C. FULLER, M.D.
Intracranial tumors are not rare, though some varieties are more
common than others: as, for example, glioma, sarcoma, tuberculoma
and syphiloma. Next in frequency, Bramwell’ places carcinoma.
But Blackburn in a series of 1,642 autopsies on subjects dying in-
Sane, while finding intracranial tumors in 29 of the cases, did not
encounter a single intracranial carcinoma, though many of his cases
exhibited carcinoma in other parts of the body. Blackburn, how-
ever, did not deny the liability of secondary carcinomatous deposits
occurring in the brain, nor the possibility of primary carcinoma of
this organ. At Westborough State Hospital, in 422 consecutive au-
topsies, intracranial tumors have been found in I2 of the subjects.
In two of these latter the growths were classed as carcinoma.
If one takes these two series from American sources as cri-
teria, representing as they do 2,068 subjects with intracranial tumor
in 31 instances, and of these latter only two, less than . I per cent.
(to be exact, .O96) of the total autopsies and 6.45 per cent. of the
total instances of intracranial tumors, it will be seen that this form
of intracranial growth is not a common finding, at least in brains of
persons dying insane. -
If with these two series are considered the figures of Knapp'
dealing with death from malignant growths at Manhattan State
Hospital, which were published in 1904, even this small proportion
undergoes considerable reduction. Knapp reports 31 cases dying of
malignant growth, five with intracranial tumors, but not one of
these latter was carcinoma. In the Manhattan State Hospital series,
the proportion of deaths from malignant growth to total deaths of
the Hospital was one in every 217, a series therefore of 6,727 insane
persons dying without a single intracranial carcinoma, although 22
of them had shown carcinoma in other parts of the body.
In the Westborough material, the two subjects with intracranial
carcinoma also showed deposits in other regions, in one an extensive
epithelioma of the right jaw, in the other a tumor in the left lung.
In the first mentioned, the deposits in the brain seemed clearly of
secondary origin, but in the second there is some doubt as to their
primary or secondary character, this, too, in spite of the not infre-
quent association of secondary intracranial tumor with tumor of the
lung. It may or may not be significant that the extra cranial growth
in each of the two cases, barring infiltration of lymphatic glands in
I62
the immediate vicinity, was limited to a single site, while in the
brain, in both instances, the tumors were multiple and, relatively,
widely separated.
Unquestionable primary epithelial tumors of the brain, however,
are among the rarest of new growths affecting this organ, examples
of which have been reported by Cornil, Benke,” Selke," Nothnagle'
and Spath." The comparatively recently published case of Kolpin'
is a questionable one, since the trunk organs were not examined post
mortem, although clinically there was no evidence of carcinoma in
the pelvis, abdomen, thorax or skin.
The case to be reported in this paper presented multiple
papillomatous growths of the cerebrum and a spherical tumor,
the size of a small orange, in the left lung. Some of the
peribronchial and peritracheal lymph glands were infiltrated;
otherwise no tumors were found in the trunk organs and on the skin.
The more advanced condition of the growths found in the brain—
haemorrhages and necrotic disintegration—and particularly the tu-
mor intimately associated with the ependyma and projecting into
the right lateral ventricle—arouse much doubt as to which was
primarily involved, the brain or the lung. In practically all of the
reported cases of primary epithelial tumors of the brain, the
growths have taken origin from the lining of the ventricles, while
secondary deposits are usually along the course of the vessels.
The case is of further interest for the reason of the mental symp-
toms which seemed chiefly, if not solely, accounted for in the mul-
tiple new growths; the sensory aphasia, easily explained by the site
of two of the tumors; and the character of the growths when the
age of the subject is considered.
The clinical history of the case is as follows:
No. 7,984, 35 years of age, a broker's clerk, was admitted to
Westborough State Hospital July 21, 1908.
Family History. The family history, as elicited, is negative
for mental and nervous disease. The father and mother of patient
died from pulmonary hamorrhage, presumably of tubercular origin;
otherwise no information of pathological or heredity importance is
reported.
Previous History. As a child, the patient was considered well,
escaping the usual children's diseases, but he was rather odd and is
said to have been impulsive. On finishing the grammar School he
went to work, and, so far as can be ascertained, had given
good service and was at least of average intelligence. He had
never used alcohol, but smoked to excess. He had been en-
gaged to be married, but three years prior to admission, for
some reason unknown to informant, the engagement had been
broken by his fiancé. Even since this affair he had acted
I63
“peculiar”—that is, he had given up his former associates and
haunts, keeping to himself at the office as much as possible, and also
when the day's work was done. He seemed discouraged, lost inter-
est in things and became slack in his work. Finally he got things
so mixed at the office—improperly directing correspondence, sending
a letter to one firm or customer which was intended for another,
transposing names of customers, ill-sorting the mail and mixing up
his other clerical work—it was impossible to keep him. This state
of affairs had been gradually progressive until about three weeks
prior to admission, when his condition became suddenly much worse.
He had all along complained of some headache and disturbance of
vision, but these were now greatly aggravated. He was also much
confused, and speech content, because of the wrong use of words,
was frequently senseless and sometimes quite unintelligible. He ap-
peared neither to recognize his mental condition nor his surround-
ings, and only partially, if at all, his friends. During a compara-
tively lucid period just before his admission, he remarked, “If I
thought there was anything the matter with me (meaning mental
disease), I would make away with myself.” Within the three weeks
he had also developed visual and auditory hallucinations, exhibited
a marked memory defect and showed a tendency to wander about,
apparently unable to get his bearings. The speech disorder in-
creased and blindness was progressive.
Here On admission to Westborough State Hospital, an ema-
ciated young man of slight build, weighing 97 pounds, exhibited an
enlargement of the area of cardiac dulness, a mitral murmur, slight
dulness over the apex of the left lung, and pyorrhoea alveolaris. No
pathological alterations were detected in the remaining trunk organs.
There was some exopthalmus; the pupils dilated and reacting to
light; no cooperation in accommodation tests; a divergent squint
and considerable defect of vision. An examination of the eye
grounds, three weeks later, revealed bilateral choked disc and pallor
and puffiness in the lower portion of the temporal field of the left
eye. There were no cranial nerve palsies. The skin and tendon
reflexes were active; no Babinsky; no Romberg. Muscular tone was
poor. There was no special disturbance of the gait, save a degree
of trepidancy such as is common with blind persons.
Mentally, the patient appeared confused, although for the most
part he remained in bed quietly, seldom saying anything unless ad-
dressed. He was unable to give an account of his past life, partly on
account of his confused mental state and defective memory, but
chiefly for the reason of the aphasic disorder from which he suf-
fered. The speech defect seemed attributable in a great degree to a
disturbance of internal language, since the tones of ordinary conver-
sation were heard by him without any difficulty, and yet many of the
I64
examiner's questions and the simplest language of ordinary inter-
course frequently seemed as unintelligible to him as a foreign lan-
guage of which he had never heard. He could not name correctly
objects placed before him, but this may have been due in part to
defective vision and in part to a degree of astereognosis, for the few
times when any attempt was made to name them he first felt them
over carefully. A pencil, piece of paper, watch and a small table
were each designated as “glassware.”
During the two weeks following admission, the speech dis-
turbance and blindness progressed, the latter becoming almost com-
plete. Although not confined to bed, he was not active about the
ward. He seemed very dull and several times had soiled himself
with urine and feces. He did not make any complaints, and seldom
said anything unless spoken to.
Aug. I3, 1908. The following questions and replies will give
Some idea of the speech disturbance at this time:
Q. What is your name?
A. Its the same thing I suppose. Nothing even. You can put
his head on.
How long have you been here?
Very seldom.
Do you know my name?
Yes sir.
What is my name?
As far as I am concerned.
Where were you born ?
Hally's anker.
What is your occupation?
That I don’t know. I haven’t the slightest idea.
. What was your father's name?
I suppose you could take it right away from him.
What is your name?
M (Correct).
. What is your first name?
George M. (Correct).
. Where did you come from ?
In this name here.
. Who is President of the United States?
United States.
Who is President?
. Oh, the other man is the one that takes it.
What is this? (watch held at patient’s left ear.)
That will do for that.
. What is this? (watch held at patient’s right ear).
I don’t know how much he is dond for.
I65
Q. What are these? (bunch of keys placed in patient’s hand).
A. They are all Americans. They are half done.
Etc.
When given paper and pencil, he wrote without direction,
George, and later, after much urging, his last name. He did not
seem to understand when urged to write his home address, nor when
he was asked to write from dictation single syllable words such as
God, man, cat, dog. All of his writing attempts were simply a per-
severation of his first name, which he wrote in a firm and legible
hand. With the left hand he wrote George with ease, although it
was somewhat ataxic. He was right-handed.
When requested to name the days of the week he counted cor-
rectly from I-25. He could not count from 25–I, saying, “I don't
know how that comes back.” He did not seem to understand when
requested to repeat after the examiner the names of the days, or even
to repeat any of the other common words which were requested.
Aug. 20, 1908. The note is made that his condition is worse.
He has been very untidy and now appears totally blind, takes no
interest in his surroundings, except when the physician speaks to
him, and then he smiles and replies in a paraphasic or jargonic man-
ner, the content of one reply frequently the perseveration of what
had immediately gone before.
(Three rather full aphasic examinations, after the scheme of
Heilbroner, were made on this man, with certain modifications since
our patient was blind, which along with other aphasic protocols made
during the past six years will be published at a later date. Attention
would be called, however, to certain reactions which were difficult
to interpret. As in most aphasic protocols, the faulty reactions in-
creased in direct proportion to the fatigue of the patient, but even
when fatigued certain successive reactions were very apt, so that
one could not determine definitely whether previous and subsequent
faulty reactions resulted from actual disturbance of internal lan-
guage, or whether they were the result of clouding of consciousness,
a clouding which occasionally cleared for short periods. Intent to
deceive by faulty reactions, it is believed, can be ruled out, and at no
time was there anything suggestive of Witgelsucht).
Oct. 6, 1908. The patient has failed physically and mentally.
He is now so weak that he can not stand without falling to the floor,
and his replies to questions are either indistinct monosyllables or
very short paraphasic or jargonic phrases. He is constantly untidy.
Oct. I2, 1908. He has carried no temperature, and since the
last note has steadily failed. He lies constantly on his back with
mouth and eyes opened, the only movement being to raise his hands
above his head in an aimless manner. He makes no voluntary state-
Inents, but the attendant reports that on one or two occasions he has
I66
said “yes” although indistinctly, when asked whether he wanted a
drink of water. Examination of the reflexes show them still active;
the left pupil is slightly more dilated than the right. There is well-
defined dulness over the entire left lung.
Oct. I5, 1908, Death. At no time was there an elevation of
temperature.
Autopsy, seven hours post mortem.
Anatomical Diagnosis.--Focal thinning of calvarium due to
pressure, Scant diploë, dura congested and tense, cerebral cauli-
flower-like hernia along antr. third of longitudinal sinus and over
frontal and parietal convexity, marked congestion of pia, cerebral
edema, multiple cerebral focal softenings of cortex, multiple new
growths involving cerebral cortex and white substance, chiefly latter,
choroid plexus and ependyma of right lateral ventricle, general
cerebral congestion, increase of cerebro-spinal fluid, congestion of
Spinal cord; chronic endocardial vegetations of mitral valve; consoli-
dation and tumor of left lung; moderate interstitial hepatitis; splenic
congestion; congestion of gastric mucosa and gut; cyanotic kidneys,
cystitis; tumor infiltration of peribronchial and mediastinal lymph
glands.
Abstract of Autopsy Protocol.—The brain is large, congested
and edematous, weighing 1815 grams. The cerebral gyri are flat-
tened, the sulci shallow. The pia of the cerebral convexity presents
a slight degree of opacity, elsewhere it is clear. The blood vessels
of the convex, mesial and basal surfaces are engorged, but collapse
on Section, nowhere presenting macroscopic evidence of arterio-
sclerosis.
Involving the posterior half of T2 and T3, on the left side, is a
semi-necrotic, spongy and gelatinous tumor mass, measuring
roughly 6 by 4.5 cm. from which exudes, when its slight adhesions
to the dura are separated, a semi-fluid, brownish material containing
yellowish amorphous particles. A similar tumor is found on the
convexity of the right occipital lobe, delimited caudally by a sulcus
semi-lunatus (Eliot Smith) and extending orally for a distance of
approximately 3 cm. This tumor is also slightly adherent to the
dura and exudes similar material as already described. In the left
frontal lobe there is an area of softening, extending from frontal
pole anteriorly to within approximately I cm. of antr. central gyrus
posteriorly, affecting portions of FI, F2, F3, but chiefly F2. The
outer cortex of this area is intact, the softened and somewhat
doughy mass chiefly sub-cortical. The second pair of cranial nerves
are flattened and atrophic, the left more markedly.
Small portions of the tumor in left temporal region, and of
softened area in left frontal, were fixed in alcohol, the remainder
of the uncut brain in Io per cent. formalin.
After formalin fixation, the brain was sectioned on a macro-
167
tome at intervals of I.25 cm. In the first section, from before back-
ward, on the left side, an oval-shaped tumor—gelatinous in portions,
finely spongy in others, and mottled with blood extravasation—is en-
countered. The tumor involves the lower cortex and stalk of F2,
portions of F3, in the same manner, and fully 3-5 of the vorona. In
the second section the same tumor is seen, but now larger, involving
nearly all of the cortex and marrow of F2, fully I-2 of FI, a great
part of F3 and about 2-3 of the corona. (Fig. Ia) The third section
which passes through the knee of the corpus callosum also exhibits
this tumor. It now involves the stalk of F and F*, and all of the cor-
ona superior and external to the callosal fibers. In the fourth section,
the tumor is considerably smaller and is confined to the corona and
a small area of the stalk of FI. In the fifth section, which passes
through the anterior commissure, where this structure bridges the
cerebral hemispheres mesially, no gross lesions are shown. The
sixth section, taken immediately anterior to the nuclei corporis
mamillaris, reveals a dilated anterior horn of the lateral ventrical, on
the right side, in which a finely spongy tumor mass is seen, involving
in this plane only the choroid plexus. The seventh section, passing
through the red nuclei rubrum, exhibits the same spongy tumor in
the right lateral ventricle. The ventricle is now considerably dilated
and all of the choroid plexus is involved, but mesially the tumor can-
not be lifted away from the ependyma, nor is there any sharp demar-
cation as to where the tumor ends and the posterior I-3 of Ammon's
horn begins. (Fig. Ib.) The eighth section passes through the sple-
nium of the corpus callosum, and reveals a still dilated right lateral
ventricle filled with the tumor mass which is now infiltrating the
surrounding structures. On the left side, another tumor mass, in-
volving the greater part (inferiorly) of T1, T2. In the ninth section,
TI, T2, T3 are involved, mesially extending to and implicating the
optic radiatons. In this area the tumor reaches its largest propor-
tions, gradually diminishing in succeeding sections to terminate 4 cm.
distant from the occipital pole. On the right side of this section
(ninth), the tumor of the right lateral ventricle is still shown, infil-
trating also the corona. (Fig. Ic.) This tumor in succeeding section
is shown to be continuous, with the tumor delimited on convexity of
occipital lobe by a sulcus semilunatus which is described above.
The choroid plexus of the left lateral ventricle, throughout, is
unaffected. The cerebellum, pons and medulla show no focal
lesions.
The left lung is free from adhesions, but is congested and con-
solidated. On section of the inferior lobe, the cut surface is moist,
and from the transsected bronchioles a blood-tinged, muco-purulent
material exudes. The superior lobe is also consolidated, presenting
in its middle third a firm, cream-white spherical tumor, approxi-
I68
mately 6 cm. in diameter. When this tumor is sectioned, a grayish
core presents, about .5 cm. in diameter and softer than the remaining
portions of the growth. In this lung, the bronchus and its main
branches are congested, the mucous surface covered with frothy,
blood-tinged, muco-purulent material. The left lung weighs 42O
grams. -
The right lung is also free from adhesions; it is small and
aerated, though congested. On Section, no pneumonic areas or
tumor formations are encountered. Weight, 240 grams.
On the left side, the peribronchial lymph glands are enlarged—
not excessively—firm in consistence and pale yellow, in color, pre-
Senting on section much the same character as the tumor in the
left lung, while the lymph glands about the right bronchus are soft
and pigmented. In the upper reaches of the mediastinal space a
few, firm, pale yellow lymph nodes are found.
The other pathological lesions have been mentioned in the ana-
tomical diagnosis. They seem to have no bearing on the brain
tumors, and so are not here described in detail.
Microscopical Examination. The characteristic structure of
the tumors in the brain is papillomatous, the stems of the papillae
of a rather loose stroma in which extremely wide capillaries are
commonly shown. The epithelial cells of the papillae are rather
generally columnar in shape, although many of them are cuboid.
(Fig. 2). Many of the sections show necrotic areas in which the
tissue presents a rather granular appearance, with a few persisting
nuclei. Microscopically the demarcation of the tumor masses from
the surrounding brain tissue is just as sharp as was shown macro-
scopically. The reaction of immediately adjacent brain tissue is
for the most part insignificant. The ganglion cells in alcohol fixed
sections stained with toluidin blue as a rule are deeply tinged and
atrophic, but there are some shadow forms. There is a glia cell
reaction, mostly large glia cells of the amoeboid type (Weigert’s glia
mordant, Mann's stain) and also macrophages of a phagocytic char-
acter, but nowhere are these changes excessive.
In the lung the tumor formation presents much the same char-
acter. Here, however, the fine structure of the tumor is more com-
pact and the cells of the papillae more cuboid in shape, and in low-
power views the picture is more adenomatous in character. There
is little doubt as to essential characteristics, which are the same as
those of the brain tumors. (Fig. 3.)
The spinal cord and medulla were without tract degenera-
tions or other lesions of significance.
Of the mental symptoms accompanying cerebral tumors there
is a considerable literature. One needs but refer to the fre-
quency with which tumor has been mistaken for general paresis.
In the case here reported the focal symptoms, as shown in the
/
I69
aphasic disorder and blindness, were more prominent than symp-
toms characteristic of any definite psychosis, and yet the case was
not without purely psychic symptoms. Aside from the tumors the
anatomical findings in the brain are not especially remarkable, at
all events, not sufficient to argue the coexistence of any of the re-
cognized psychoses, so that one is forced to the conclusion that
the tumors in the brain were solely accountable for all of the men-
tal symptoms which this man presented, and certainly the focal
symptoms are well explained by the site of two of the tumors.
REFERENCES
I. Bramwell. Clinical Studies, Vol. VIII, p. 19, Edinburgh, R & R Clark,
I9IO. -
2. Blackburn. Intracranial Tumors Among the Insane. Washington, Govt.
Printing Office, 1903.
Knapp. Notes on Malignant Growths in the Insane. Am. Jour. Insan.,
Vol. LX, p. 451, 1904.
Cornil. Cit. by Kolpin l. c.
Benke. Cit. by Kolpin 1. c.
se: Epitheliales Carcinom des Gehirns. Inaug. Dissertation, Konigs-
erg. * , -
Nothnagel. Ueber Tumoren der Vierhugeln. Wiener med. Presse, 1889.
Späth. Primărer multipler Epithelkrebs des Gehirns. Inaug. Disserta-
tion, Munich, 1882.
Kolpin. Multiple Papillome (Adeno-Carcinom) des Gehirns. Archiv f.
Psych. Bö. 45, p. 595.
EXPLANATION OF PLATES.
FIG. I.-a. Coronal section taken through one of the tumors. The tumor
is sharply delimited. Anterior view.
b. Showing a tumor growing from the ependyma into the ventricle and
also involving the choroid plexus. Posterio view. e
c Showing tumor involving TI and T2 on left side and the continua-
tion of the ventricular tumor on the right side. Posterior view.
FIG, 2–Section of one of the cerebral tumors. Alcohol fixation, toluidin
blue staining. The illustration is characteristic of all the tumors found in
the brain of this case Bausch and Lamb 2-3 achromatic obj., no ocular, bel-
lows extension 180 cm. - ---- º
FIG. 3–Section from the tumor in the lung Zenker fixation eosin-
methylene blue. Photographic details as in Fig. 2.
WESTBO ROUGH STATE
PLATE XXX.
HOSPITAL PAPERS (Series I)

WESTBO ROUGH STATE HOSPITAL PAPERS (Series I)
PLATE XXXI.
Fig. 2

WEST BOROUGH STATE HOSPITAL PAPERS (Series I) PLATE XXXII.
º, -º-º:
º
Fº


XII
A CASE OF MONGOLIAN IDIOCY.
BY WALTER A. JILLSoN, M.D.
W. S. H., No Io,077. A boy, age 13, was admitted to the
hospital on April 6, 1912, as a thirty-days’ observation case be-
cause of certain psychic manifestations which had made his care
and management at home impracticable.
Family History.—Father is living but in poor health, being an
arrested case of tuberculosis. Mother died shortly after patient’s
birth from causes the result of her severe parturition and puerpe-
rum, previously having been a healthy, normal woman of normal
stock, so far as can be learned. Paternal grandfather living, has
twice been an inmate of insane hospitals; paternal grandmother and
an aunt are neurotic.
Personal History.—Patient was a full-term, instrumentally-de-
livered, artificially-fed infant. As the result of instrumentation
the head was badly injured, so much so as to cause a grave prog-
nosis as to the possible continuance of life. Though he did live,
he was delicate, and backwardness has always characterized his
mental and physical development,
The ability to walk and to talk were not accomplished until
the age of four; neither has ever been normal. Comprehension
was good at a much earlier age. When about the age of four or
five he had periods of stupidity; then, for about a year, was very
bright, learning rapidly. Following upon associations with other
children, he developed a serious, excitable period, when for about
two years he had uncontrollable spells, during which he would
use profane language and would run his fingers far down his
throat. During these years he required special care, and he led an
out-door life, with the result that he was able to take up home les-
Sons, but these were interrupted by occasional. lapses in his mental
Condition and behavior.
Instruction in the ordinary branches of common school knowl-
edge has always been under the private tutelage of an aunt, with
whom he has lived since the age of five, and has been slow and in-
termittent because of mental incapacity and numerous physical
ailments, to which latter he seemed to be especially susceptible.
Speech has always been slow and drawling.
He has sustained several accidental injuries in the past, many
of them being the result of his clumsy, awkward ways. Two
Severe falls, both accompanied by unconsciousness and other
I72
signs of probable concussion, are to be noted, one occurring about
five years ago and the other last January, the latter being followed
by the train of mental symptoms which made his commitment
necessary. }
He has always had a childish manner and a tendency to affect
a make-believe-like-Others attitude in his words and acts, so that,
Superficially, he has often appeared wiser than his years.
In early childhood he exhibited a propensity to lick various
objects, and later on in life was occasionally noticed to bite in a
Sort of playful way, though never to such an extent as to fail to
control himself when remonstrance was made.
Present Psychosis began following probable cerebral con-
cussion resulting from fall on the ice last January. Though he
was able to walk to the house and to tell how his accident oc-
curred, he showed speech disturbance within an hour and emesis
within two hours, the former disappearing after about six hours
and the latter lasting about six or seven hours. He appeared
dazed but was at no time unconscious, and once when he tried
to get to his feet he fell to the floor.
About a week later, while convalescing and out walking with
his aunt, he again slipped on an icy sidewalk and fell, complaining
that he could not see well, and again experiencing difficulty in
walking. The next morning, while lying on the couch unusually
quiet, he was called from an adjoining room by one of his aunts to
assist her at Some light task. He went to his aunt silently and
seemingly was about to assist her, when suddenly and without the
least warning he started to bite her. The combined efforts of two
aunts, his grandmother and later a man were necessary to restrain
his violence. During this episode he not only struggled in his at-
tempts to bite, but scratched, kicked and screamed at the top of
his voice.
After being controlled he remained good for about a week,
opiates being administered and special observation and care re-
quired. Only occasional mild spells of violence occurred during
this time. He then relapsed, bit his aunt and three days later
was practically uncontrollable, except by force, and so much so that
the constant services of a male attendant were required to re-
strain his violence. Associated with this period were frequent im-
pulses to masturbate. *
The boy realized his changed mental condition and often
piteously asked his relatives and nurses to help him to be good and
control himself. There was mental dulling, and, with excited spells,
great talkativeness with tendency to flight of ideas. Previously
reliable in his promises, he became unreliable and would excuse
himself by saying that he could not help it.
I73
Hospital care and treatment became necessary simply because
all connected with him were becoming exhausted with his care.
Here.—Upon admission he was extremely violent and given at
short intervals to periods during which he would bite and scratch
those about him, was tearfully emotional and homesick, but when
Spoken to became cheerful, hopeful and optimistic. He answered
questions readily, coherently and relevantly, but spoke in a slow,
drawling, affected manner; made good responses to simple educa-
tional tests, consistent with advancement reported by relatives; and
shortly became restless, could not be quieted and examination had
to be discontinued.
The following day he was found to be oriented, showed no
gross memory defects and gave no evidence of hallucinations or
delusions. He was very suggestible, and when biting was men-
tioned, immediately went towards the examiner, grasped his hands
and attempted to bite them. During his biting attacks he bit and
scratched everyone who went near him; his face became con-
torted, his forehead wrinkled and the corners of his mouth
turned down and presented the appearance of one about to cry.
Alone and unobserved he would become quieter, but as anyone
entered his room he would immediately leave his bed, go towards
the visitor and attempt to bite.
Physical Examination.
General Condition.—A well-nourished boy, height 4 feet Io
inches, weight 84% lbs. ; head asymmetrical and features of Mon-
golian type; palpebral fissures narrow and slanting and well-de-
fined epi-canthal folds; cheek-bones high ; ears large and protrud-
ing; hair brown. long, coarse, and bushy; hands short, stubby and
thick-set, with disproportionate shortening of thumbs and little
fingers, the latter showing characteristic incurving; tongue, unlike
usual findings in these cases, was short and thick rather than long.
Cephalometrical Measurements.
Circumference, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52.5 C.m.
Inion to nasion, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36. c.m.
Binauricular arc, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38. C.m.
Arc of right auricular point to nasion, . . . . . . . . . . . . . . . . . . . . I5. C.m.
Arc of left auricular point to nasion, . . . . . . . . . . . . . . . . . . . . . . I4.5 C.m.
Arc of right auricular point to inion, . . . . . . . . . . . . . . . . . . . . . . I4. C.m.
Arc of left auricular point to inion, . . . . . . . . . . . . . . . . . . . . . . . . I4. C.1/1.
Diameter, inion to nasion, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I7.8 c.m.
Diameter, inion to glabella, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I9.2 C.m.
Bi-parietal diameter, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I5. C.m.
Binauricular diameter, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I3.5 C.Iſl.
Length-breadth index, 80.33 (slightly brachycephalic),
/
I74
Neurological—Station faulty, showing inability to stand with
feet close and eyes closed without falling after thirty seconds
(Romberg); gait awkward and shuffling with tendency to drag toes
and to stumble and fall easily; pupils equal, regular and reacted
normally; patellar reflexes markedly exaggerated; otherwise noth-
ing of importance.
During period of observation at this Hospital he remained
quite excitable, suggestible and violently inclined for the greater
part of a week or more, but as time went on he became more amen-
able to discipline and ward routine, and his vicious, emotional at-
tacks became less frequent and intense, though at no time during
his residence here did he become wholly unsusceptible to sug-
gestion when biting was mentioned. !
He was discharged improved at the expiration of his period
of observation, going to the care of his father, who has since had
him committed to the Wrentham State School.
Summary.—The foregoing case appears to us to be one of
Mongolian idiocy, our opinion being based upon the physical stig-
mata as noted in the paragraph describing his general condition.
(See Figs. I and 2). To his constitutional mental inferiority was
added a psychosis and his congenital physical defects were compli-
cated by neurological lesions, possibly the results of parturitional
injuries.
EXPLANATION OF PLATES.
FIG. I.--To illustrate the characteristic Mongolian cast of features.
FIG. 2.-Characteristic appearance of hands in cases of Mongolian idiocy.
WESTBO ROUGH STATE HOSPITAL PAPERS (Series 1) PLATE XXXIII.

WEST BOROUGH STATE HOSPITAL PAPERS (Series I) | PLATE XXXIV.

XIII
ALZHEIMER'S DISEASE (SENIUM PRAECOX) THE REPORT
OF A CASE AND REVIEW OF PUBLISHED CASES-k
By SoLoMon C. FULLER, M.D.
The first published case presenting the combination of clinical
Symptoms and microscopical changes discussed in this paper was
reported by Alzheimer (I) in 1906. Since then similar obser-
vations have been recorded by Bonfiglio (2), Sarteschi (3),
Perusini (4), Barrett (5), Alzheimer (6), Bielschowsky (7),
Lafora (8), Fuller (9), Betts (IO), Schnitzler (II), and Jansens
(I4). 2
The case described here is included as an example of Alz-
heimer’s disease in the report on a group of 93 brains exam-
ined with reference to origin, diagnostic significance and finer
structure of so-called senile or Fischer's plaques. Owing to the
variety of psychoses included in the earlier communication, the large
number of clinical abstracts and the abbreviated manner in which
the case was presented, a further report is undertaken. The
chief reason, however, for this elaboration and the review of all
published cases known to the writer, is furnished by the lively
interest shown in the type of mental disorder to which Alzheimer
was the first to call attention. The cases from the literature are
given below in chronological order, the clinical abstracts in full,
and the anatomical findings summarized in the discussion.
While more or less definite mental symptoms and structural
alterations are referred to in this paper, the recorded cases are
too few—even these showing important variations—to warrant
maintaining anything comparable to the paradigm of general
paresis. The earlier reports, along with other details mentioned
in their microscopical descriptions, emphasize the combination
of miliary plaques with a certain basket-like appearance of gan-
glion cells occasioned by a peculiar alteration of intracellular neu-
rofibrils. But within the present yearſ Alzheimer himself has
published a case in which numerous large miliary plaques of the
brain were a striking feature, but in which no ganglion cell
exhibited the peculiar type of alteration. (Vide infra Alz-
heimer's second case.) The last recorded observations (Schnitz-
ler's case) note the Alzheimer degeneration of ganglion cells,
but not a single plaque was found in the many areas of the brain
examined. The busy delirium, excitement and confusion which
*This paper is reprinted by courtsey of the Journal of Nervous and Mental Diseases, where
it was first published in the July and August, 1912, numbers.
f 1911.
176
have characterized the clinical course of some of the cases have
been wanting in others, their place being taken by an apathetic
dementia. The aphasic symptoms and ideational apraxia have
also failed in some of the cases. Nevertheless, when this has
been Said, it must also be said that the clinical and anatomical
findings offer a striking similarity. Although the total number
Of cases is small upon which the conception of this type of mental
disorder is based, the assumption of a clinical type or subgroup is
not altogether unwarranted. These cases clearly indicate that
psychoses occurring in or about the period of senium are a rich
field for clinical and anatomical research. The Westborough
case is presented as cumulative data toward the isolation of a
type which while lacking at present some of the postulates' of
a disease entity may yet crystallize into such.
W. S. H., No. 9,378, a man 56 years of age, for some time
previous to his final breakdown (about two years), had shown a
memory defect, short periods of apparent unconsciousness or
dream-like states, verbal amnesia and Occasional paraphasia, but
had been able to continue at work as a laborer on a farm where
he had been employed for many years. His sister states that the
memory defect had been gradual, and while at first the short
periods of confusion (of a few minutes’ duration), in which he
spoke in a paraphasic or senseless manner, were only seldom ob-
served, of late these had become very frequent. Recently, even
when there was no apparent mental confusion, he often seemed
unable to find the proper word or words to employ in ordinary
conversation. He would often search for things which lay
directly before him, and would use familiar objects incorrectly
(apraxia). Within the last six months when he had visited his
sister's home, he would relate to her, over and Over again, the
same experience within the course of a few minutes, apparently
forgetting that he had already done so. On going to bed, he would
make separate bundles of his clothing, placing one here, another
there, in out-of-the-way places, and in the morning could not
remember what he had done with his things.
Twenty years ago he had separated from his wife on account
of her infidelity. This affair had worried him quite a little, but he
formerly never spoke of it to any one. Of late, however, he
constantly referred to his wife in conversation, wondered where
she was and whether he had done the proper thing in leaving
her. As a result he was slightly depressed. It appears that his
wife was certainly at fault, while he has always borne a reputa-
tion for integrity and industry. He was the father of three chil-
dren by this union, one of which died in infancy from cerebro-
spinal meningitis, the others now of age and in good physical and
mental health.
177
About ten days prior to admission to hospital, he had a “mild
attack of influenza with which marked mental symptoms were
associated. During this attack he had been very restless, par-
ticularly at night, roamed about the house, talked much about his
work, and went through movements as though employed at his
usual daily tasks. Finally, he began to tear the bed-clothing, was
manifestly disoriented and confused, apparently forgot move-
ments employed in dressing and feeding himself and lost control
of bladder and rectal function, or at least performed these latter
functions without regard to ordinary rules of decency and
tidiness. -
The mother of patient died of apoplexy at theage of 61,
father at about 65 from an affection of the stomach. No other
family history of importance elicited.
On admission to Westborough State Hospital, Jan. 27, 1911,
he was in a fairly well nourished condition, but looked older than
his stated age (56) and presented in his person the appearance of
neglect. The gait was rather unsteady but not characteristic of
anything more than a general weakness combined with what
appeared to be a senile trepidancy; no evidence of paralysis de-
tected. A systolic murmur, best heard at the apex, a full and
rapid but regular pulse, firm radial and temporal arteries were
present. Respiratory movements were of the costal type; bron-
cho-vesicular breathing and a few rāles on right side.
The pupils were slightly irregular in outline but of equal
diameter, reacting sluggishly to light, the right more sluggishly
than the left. Accommodation tests unsatisfactory owing to
lack of proper cooperation. Acuity of vision could not be de-
termined. The patient also failed to cooperate in tests for hear-
ing and for the same reason integrity, or the extent of impair-
ment, of taste, olfactory and tactile sensibility could not be defi-
nitely determined. As noted above, there were no paralyses, no
contractures. Muscular development was fair but rather flabby.
Coordination tests were poorly executed; no Romberg; tendon
reflexes increased. No history of lues or cerebral insult was
obtained. He had used alcohol moderately.
When first seen by examining physician he was very som-
nolent and could be aroused only with difficulty. Mentally he
was not only dull but apparently indifferent, was disoriented for
time, place and persons and was without grasp on his surround-
ings. Speech reactions were slow, indistinct—often degenerat-
ing into a scarcely audible jargon—data frequently incorrect.
There was often a logoclonic repetition of the last word of a sen-
tence or last syllable of a word, and with fatigue, easily evoked
he became paraphasic. Memory defect was marked for the
grossest events of his life, the recent as well as the remote.
178
. What is your age? A. Charles E. G.-,
What is your age? A. Charles E. G.-.
. What is your age? A. Fifty-ty-ty-ty.
. How old are you? A. Fifty-six.
. Where were you born? A. Unintelligible muttering,
then finally, Watertown.
Q. Where is your home? A. My home was born in Boston
I Suppose by my mother and her name was Stagpole. (Maiden
name of mother was Stackpole.)
Q. Where is your home? A. I have no home but hopple
popple home all the time.
Q. Where are you now? A. I know I am from another room
as where from another room.
Q. What kind of a place is this? A. Kind of a wooded play,
Etc.
He was able to name and indicate the use of objects shown
him—pencil, knife, keys, watch.
When given pencil and paper and directed to write his name
and address, he grasped the pencil in a proper manner, placed the
paper on a hard surface and laboriously made a few marks but
did not form a single letter. Questioned whether or not the
marks were intended for his name he replied “yes.” Repeated
attempts were equally futile. -
Jan. 28, 1911, the day following admission, he was a little
brighter mentally and for a while during the interview with
examiners he answered questions readily and in an orderly
manner, but he was still disoriented. He could not tell how long
in hospital, the nature of the institution, or remember that he
had seen one of the examiners on the evening previous. He
showed no concern when informed as to the character of the hos-
pital. “Garfield is president” and he had “never heard of
Roosevelt.” He did not know whether his wife was dead or
alive, at first maintaining that she was alive, later that she had
been dead two years. During the interview, he frequently ex-
hibited a verbal amnesia and was occasionally paraphasic. He could
name objects shown him—bedroom furniture and small articles
such as are carried on the person—and execute simple commands,
but easily became confused with more complex tests, such as: three
pieces of paper of different sizes of which he was directed to
tear up the largest, give the middle sized one to examiner and
put the other in the pocket of his bath robe. Go to the window,
knock on the pane, come back and sit down, etc.
Feb. 3, 1911. Following the last note he was very noisy and
restless at night; frequently confused and destroyed the bed-
clothing.
:
179
Feb. 7, 1911. Rapid physical and mental failure; very un-
steady on feet; for two days previous he had failed to respond
to all questions; remained in bed, constantly disturbing the bed-
clothing or moving his arms about in a purposeless manner.
Frequent unintelligible mutterings; extremely resistive.
Feb. 8, 1911. Pronounced clonic spasms of the left shoulder;
clouding of consciousness; labored breathing; difficulty in Swal-
lowing; extreme resistance. &
Feb. 9, 1911. Death with symptoms of broncho-pneumonia.
Autopsy I6 hours post mortem.
Anatomical Diagnosis.-Chronic external pachymeningitis,
hernia of Pacchionian granulations through the dura, chronic
hypertrophic leptomeningitis, pial congestion and moderate pial
edema, advanced cerebral arteriosclerosis, regional atrophies of
cerebrum (frontal right and left, and temporal left); chronic
endocarditis; bronchopneumonia; chronic perihepatitis; chronic
perisplenitis; moderate chronic interstitial nephritis. '
The brain, with pia attached and before sectioning, weighed
1,445.8 grams. While within the accepted range of normal
weights, focal cerebral atrophies were displayed in the frontal
regions and in the left temporo-sphenoidal lobe, atrophies not
accounted for by previous hæmorrhage, softening gumma or new
growth. Section of cerebrum, pons, medulla and cerebellum
were negative for coarse focal lesions other than the atrophies
mentioned. The larger vessels of the base and many branches
of the mesial and convex surfaces of the cerebrum were scle-
rotic, tortous and did not collapse on section, besides exhibiting
atheromatous patches which imparted a beaded effect. The lin-
ing of the ventricles was smooth; the ventricular capacity within
normal range; cysts of choroid plexus. The spinal pia was
slightly clouded and presented several small osteomata, occurring
chiefly in the ventral portion of the thoracic distribution of the
membrane. The cord shared in the general congestion, other
than this offering no gross lesions. The microscopical examina-
tion revealed the following:
Mesoblastic Apparatus.--The pia in alcohol-fixed sections
stained with toluidin (frontal, precentral, temporal and calcarine
regions) shows that the thickening noted macroscopically is due
chiefly to a proliferation of connective tissue fibers and fibro-
blasts, presenting a meshed appearance in which are cells of
variable size containing lipoid granules (Abraumgellen). The
frontal pia presents the greatest number of such cells, though
they are by no means scant in the other areas examined. Not
infrequently they are found in great numbers in the portion of
the membrane immediately adjacent to the cerebrum, but dis-
I8O
posed in a single layer which extends for some distance. Infil-
trative phenomena, Save for an occasional mast cell, fail com-
pletely. Haemorrhages of variable size, though never large, are
present chiefly in the frontal distribution of the pia; and clear
Spaces within the thickened membrane, sometimes beneath and
lifting the membrane from the cerebrum, are also seen, the result,
in all probability, of the edema noted macroscopically. Practi-
cally all pial vessels exhibit a proliferation of the adventitia and
proliferative as well as regressive alterations of the endothelium,
the latter shown by a rich lipoid content of the protoplasm of
cells. The blood vessels of the cortex rather generally, but par-
ticularly in the frontal areas, are increased, packets and evidence
of budding are common, and in low-power views the richness
of the vascular apparatus is at once striking. With high magnifi-
cations aside from the progressive-regressive phenomena in ves-
sels of larger caliber, one encounters large cells with a rich
lipoid content, of the same general character as those noted in the
pia. Such cells are found in the perivascular spaces as well as
within the adventitia. There is scarcely a blood vessel in which
the protoplasm of endothelial cells is not plainly visible and in
which such cells do not show a pigmentation of their protoplasm.
In toluidin specimens, the pigment or lipoid content mentioned is
either unstained, presenting then its natural yellow color, or is
tinged a greenish or bluish yellow. But in frozen sections
stained with scarlet after Herxheimer, these lipoid granules are
colored a bright red and, because of a like appearance in the
majority of ganglion and glia cells, are the most characteristic
elements in sections so treated. Occasionally a small cortical
vessel presents the appearance of a hyaline degeneration. As
in the pia, the vessels of the cortex and marrow are without in-
filtrative phenomena, save for an occasional mast cell—and of these
not more than a half dozen are encountered in all of the sections
mustered.
Glia.-The stellate cells of the molecular layer are increased
in number, many showing fairly distinct processes and compara-
tively abundant protoplasm, even in alcohol sections stained with
toluidin blue after Nissl. Their general form, however, is better
displayed with Mann's eosin-methylene blue solution, Mallory's
phosphomolybdic haematoxylin, Van Gieson's stain—after bichro-
mate fixative—and also quite well by Bielschowsky’s silver alde-
hyde method, while their lipoid content is best shown by Herx-
heimer’s method. Rod-shaped cells (Stäbchenzellen) are quite fre-
quently encountered, particularly in the three outer cortical laminae,
but these appear to be of glial origin, not a few of the so-called tra-
bant or satellite cells being of this form. Colonies of proliferating
I8I
glial cells, mostly small elements, are seen throughout all the cor-
tical laminae and in the marrow, but most numerous in the molecu-
lar layer and white substance. Glial nuclei are rather generally
increased. Cellular gliosis, particularly in the neighborhood of
many blood vessels, is shown by all cell methods, and with Wei-
gert glia fiber stain, also with Mann's stain, a glial fibrillosis in
excess of the normal is demonstrated. A striking feature is the
absence of any particularly marked satellitosis; indeed, about
many ganglion cells showing most advanced degeneration of the Alz-
heimer type satellites are often wanting. Giant glia cells of the
Deiter's variety are conspicuous by their extreme paucity, even
in the white substance. The glia “keel” in XVeigert preparations
is increased in etent and a richer fibrillosis than usual is shown.
Nervous Elements.-Low magnifications of sections stained
with toluidin blue, particularly in the prefrontal areas, to a less
degree in the other areas examined, reveal a disappearance of
ganglion cells, following no definite plan, although perhaps most
pronounced among the smaller pyramidal cells. With the oil
immersion, striking features are extreme fuscous degeneration
of ganglion cells, not confined to the basilar portion but dis-
tributed in many instances throughout the protoplasm, including
such processes as are visible, large vacuoles in cells, atrophic
cells, incrustations, extreme tortuosity of apical dendrites and
shadow forms. Striking exceptions are the Betz cells of the
paracentral lobule and anterior central cortex which for the most
part exhibit a fair preservation. The fat content (lipoid sub-
stances) of the altered ganglion cells is best shown in Herx-
heimer sections, in many cells beautifully displayed in the den-
drites. With the Bielschowsky silver impregnation method,
easily the most characteristic findings are the presence of a great
number of plaques of variable size and numerous ganglion cells
exhibiting a basket-like alteration—Alzheimer degeneration.
The plaques are also well demonstrated with Mann’s solution,
acid fuchsin light-green stain, Van Gieson, though indifferently, tol-
uidin blue on frozen sections, and negatives of them are seen in
sections stained by the Wolters-Kultschitzky method for myelin
sheaths. With Herxheimer’s stain on frozen sections—a
method in my hands usually unsuccessful for plaques—not a few
of these structures were displayed, the whole plaque stippled
throughout with fine red granules, paler and smaller than the
lipoid granules in ganglion and glia cells and in cells of the vas-
cular wall already noted. The plaques are distributed without
special reference to cortical stratigraphy and are also seen in
good number in the marrow stalk of gyri. The greatest richness
was exhibited in the frontal, left temporal and hippocampal areas.
I82
These structures were also found in the basal ganglia (lenticular
nucleus, thalamus), in the brain stem and in the medulla. In the
cerebellum no typical plaques are found but not infrequently with
the Bielschowsky method, toluidin blue and in sections stained
with Mann's solution, single amyloid bodies or groups of such
are found in many foliae, usually in the molecular layer, rarely in the
granular, and white substance, around which a reactive cel-
lular and fibrillary gliosis of a mild degree is shown. In general
the number and distribution of plaques correspond with the
distribution and intensity of general histological alterations.
Since these latter are generally diffused through the brain,
plaques are also diffused. Recent and old plaques are present,
differentiated by glial reactions in their vicinity, and of the same
character as I have described elsewhere (9). Very small plaques,
not much greater in diameter than a large lymphocyte of the
blood stream, and plaques nearly equalling in diameter the depth
of a cortical lamina were found, and between these extremes all
sizes. The rosette form and the radiary actinomycotic shapes
were present as well as mixtures of these types, their finer compo-
sition such as I have described elsewhere (9).
Many ganglion cells, fully two-thirds of those in the frontal
Sections, all of the ganglion cells in the islands of the plexiform
layer of the hippocampal gyri, all of the large pyramidals of Am-
mon's horn, exhibit the Alzheimer type of degeneration. This
degeneration consists of a tangled mass of thick, darkly staining
Snarls and whorls of the intracellular fibrils, evidences of which
are also shown in sections treated with Mann's solution. One
sees occasionally in preparations where Alzheimer degenerations
is demonstrated, finer fibrils, more of the character of normal
fibrils, which appear to emerge from the thick bundles. Such
pictures suggest the possibility, as Bieilschowsky points out, of an
incrustation of neurofibrils with foreign stuffs of pathological
metabolic origin. Alzheimer had interpreted these coarse fibrils
as the result of a welding together of degenerated neurofibrils
which had undergone a chemical alteration, staining by other
methods not ordinarily displaying neurofibrils. Fischer speaks
of these intracellular alterations as coarse-fibered proliferation of
the neurofibrils of ganglion cells (grobfaserige Fibrillenwuch-
erung der Gangliengellen).
Resumé.-While data concerning the early history of the case
is meager, this may be said: a man of 56 began to show mental
symptoms at the age of 54. These were: defective memory,
speech disturbances of a sensory character, transitory periods of
confusion and a gradually progressive mental weakening, culmi-
nating during an attack of influenza in marked mental confusion,
183
ideational apraxia and untidiness in the passage of urine and
feces. During a hospital residence of twelve days, somnolency
alternating with periods of busy delirium, excitement and speech
disturbances of a 'sensory character, were observed; at the end,
clonic spasms of shoulder muscles, clouding of consciousness
and broncho-pneumonia. Unfortunately, a Wassermann or Nogu-
chi test was not made, but the later anatomical findings did not
indicate previous luetic infection.
At autopsy, regional cerebral atrophies and arteriosclerosis of
larger vessels were noted. Microscopically, vessel proliferation,
progressive-regressive changes in vessel walls but no infiltrative
phenomena, cortical devastations, atrophic and richly pigmented
ganglion cells and the presence of so-called Alzheimer degenera-
tion in many such cells, cellular and fibrillary gliosis, the former
mostly of small elements, the latter chiefly of delicate caliber,
were seen, also numerous miliary plaques in all areas of
the cortex, basal ganglia, brain stem and medulla, and marked
Alzheimer degeneration. No evidence of cerebral lues or gen-
eral paresis was present. In short, a clinical and anatomical pic-
ture in many respects not unlike the severest form of senile
dementia and yet in other ways quite distinctive. The writer
considers the case one of Alzheimer’s disease (senium praecox)
and its similarity to other published observations may be seen
in the following cases from the literature:
I
(Alzheimer's first case, also reported as Perusini's Case I,
translated from Alzheimer’s originally published notes, 1. c.
A woman, 51 years of age, presented as the first most striking
mental symptom, ideas of jealousy concerning her husband.
Soon after, a rapidly developing mental weakening was noticed;
she would lose her way about in her own home, throw things
around and hide herself for fear of being killed.
In hospital, she seemed perplexed, was disoriented for time
and place, occasionally complained that she understood nothing
and of an inability to express her thoughts. She frequently
greeted the physician as a social caller, making excuses mean-
while that her housework was still unfinished. At other times,
she would cry out in fear thinking that the physician would cut
her or evidence distrust of him, believing that her honor would
be assailed. At times she was delirious; tossed the bed-clothing
about, called out for her husband and daughter and appeared
to have auditory hallucinations. Frequently she shouted loudly
for hours at a time.
Whenever she was unable to mentally grasp a situation she
I84
would cry out loudly, this, too, whenever an examination was
attempted. Only through repeated and patient effort was any-
thing finally obtained from her. Retention (Merkfühigkeit) was
markedly impaired. When shown objects she named them for
the most part correctly, but immediately forgot them. In read-
ing she went from line to line spelling out the words or read
without inflection. In writing she repeated many syllables, left
out others, but executed the tests rapidly. In speaking she
misplaced words—Occasional paraphasia—and perservation was
frequent. Many questions asked her were apparently not under-
stood. The gait was undisturbed and use of the hands was
equally good. Patellar reflexes were present; radial arteries
firm ; no increase in the area of cardiac dullness; no albumin in
the urine.
In the further course of the disease the focal symptoms were
Sometimes more pronounced, sometimes less so, but throughout
never intense. The patient finally was completely demented;
confined to bed with contractures of the lower extremities; and
passed urine and feces involuntarily. In spite of greatest care
decubitus developed. Death after a duration of 4% years.
The autopsy revealed a diffusely atrophied brain without mac-
roscopic focal lesions, the larger cerebral arteries sclerotic.
In Sections handled after the Bielschowsky silver impregna-
tion method a striking alteration of the neurofibrils was shown.
In an otherwise seemingly normal cell there appears, at first, one
or more fibrils which on account of increased thickness and in-
creased tingibility stand out prominently. In the further course
of the alteration many neighboring fibrils are similarly affected.
These, then, form thick bundles which gradually come to the
surface of the cell. Finally, the nucleus and cell disintegrate and
only a tangled bundle of fibrils remains to indicate the site of a
former ganglion cell.
That these fibrils are colored by other staining methods which
do not display neurofibrils indicates a chemical alteration in the
fibril substance. This can well be, for the fibrils survive the
destruction of the cell. The alterations in the neurofibrils appear
to go hand in hand with a deposition of not yet definitely deter-
mined pathological metabolic stuffs. About I-4 to I-3 of all gan-
glion cells of the cerebral cortex exhibited this peculiar altera-
tion of the fibrils. Many ganglion cells, particularly in the
upper cell laminae, had disappeared.
Throughout the entire cortex, especially numerous in the outer
layers, were found many miliary foci, the result of a deposition
of peculiar stuffs in the brain substance. These foci may be
recognized without staining, but are very refractory to staining
methods.
185
There was a rich proliferation of glia fibers and many glia
cells exhibited large fat sacs. There was no infiltration of the
walls of vessels, but proliferative changes of the endothelium
were demonstrable and occasionally vessel proliferation was en-
countered.
* II
(Bonfiglio's Case, also reported as Perusini's Case IV, trans-
lated from the German of Perusini (4).)
Schl. L., a judge's secretary, 63 years old.
A brother was insane. In early life the patient had been a
heavy drinker. He had had gonorrhea; in 1870 syphilitic infec-
tion and since 1872 had suffered from a spinal affection—sensa-
tion of numbness and heaviness in the legs, occasional involun-
tary passage of urine.
In 1902 he went to hospital on account of his spinal trouble.
At that time he looked older than his reported age; the skin
of the face and neck was a light grayish blue color (had been
treated for a long time with silver nitrate); right pupil larger
than the left, pupillary reflexes intact; an old scar on the hard
palate; marked disturbance of coordination of upper and lower
extremities; impaired muscle sense; Romberg sign. No paraes-
thesias were present. For the most part he was happy and
elated and expressed himself in a friendly and orderly manner.
Nevertheless, there was a marked memory defect. When 1eft
to himself he spoke in a loud tone, his gaze directed at the ceil-
ing or window. He gesticulated freely, laughed and scolded
occasionally and stroked his face and hair in a stereotyped
manner. He would carry on imaginary conversations with his
judge; hold court and condemn the fancied prisoners to death or
drive them from the court room. Often he entertained himself
in imaginary social gatherings, conversing with acquaintances
of his student days. He declared one person a prostitute, pro-
tested against the supposed objections of another or made pro-
tective movements against fancied threats. He believed it to be
summer and that he had been already a half year in hospital.
On account of his mental condition he was transferred on the
following day to the psychiatric division.
To be added to the physical findings are: diminution of the
strength of the legs and diminished pain sensation in the right
leg. He suffered during his residence in hospital quite a little
from diarrhoea; he smeared himself with feces and was almost
constantly hallucinated (auditory).
June 20, 1904, he was transferred to Karthasbrüll unim-
proved. On admission there the pateller reflexes were noted as
I86
diminished, the pupillary reactions sluggish. He romanced
freely: he was not a pensioner, an acquaintance was a bishop.
He conversed continuously with voices. Marked memory de-
fect; marked disturbance of retention. He could remember
nothing of his stay in the Munich hospital, nor anything of his
thirty years activity as an official of the court.
Oct. IO, IQO4, the patellar reflexes could not be elicited.
There were marked disturbance of equilibrium with eyes closed,
increasing ataxia and marked euphoria. A
March IO, Igoş. A fainting attack followed a bath, but from
which he quickly recovered.
Dec. I3, 1905. Increasing divergence strabismus.
March 2, 1906. Unable to walk, remains constantly in bed.
April 3, 1906 Purulent catarrhal cystis.
Aug. 25, 1906. Chatters the day long with voices.
Dec. 31, 1906. Subnormal temperature; pulse barely per-
ceptible.
Jan. I, I907. Exitus letalis.
III
(Sarteschi's Case.*)
. . . A woman, 67 years of age, pensioned overseer of an in-
firmary, admitted to the insane hospital April 22, 1907. &
Her physician sent this history: “For about two years she has
been taciturn, melancholy, shown a tendency to Somnambulism
(sic) rises at night and tries to go out of the house. The first
symptoms were talking to herself and a tendency to go out of the
house alone, especially at night.” **
This woman had been an overseer of an infirmary and an at-
tendant in an insane hospital for about 30 years, until the begin-
ning of 1901. The physicians and all the personnel remember her
as a woman of excellent character, fair intelligence and honest hab-
its. Physically she was always healthy; no history of the usual
diseases. In the early part of 190I she got a splinter in her right
hand necessitating an incision and painful treatment. She was then
granted a pension and placed in a family at Lucca. After three years
(1904) the disturbances reported above by a certified physician
began.
On April 22, 1907, she was sent to the insane hospital.
Physically there was nothing of importance. Mentally her
condition uniformly, until the day of her death, may be described
thus:
She presents a pleasant face, is complacent, attentive and al-
* The translation of this case from the Italian was done by Stella B. Shute, A. B., assist
ant in histology, Westborough State Hospital.
187 *.
ways affable and polite. When the physician passes she rises to
her feet saying, “Good day, Signor.” When asked, “How are
you?” replies, “Well, and how are you?” and when the conversa-
tion ends she withdraws saying, “Come again and thank you, it is
impossible to know such things as you wish, excuse me and thank
you again.” Invited to be seated she fences and gracefully invites
the sister who accompanies her to sit instead. Often during the
conversation she turns to the sister who is standing and repeats
courteously the invitation, “Pray be seated.”
Asked her name, she responds with name and surname. To
all the other questions which relate to her personal history and
orientation for place and time, replies “I do not know, truly I do
not remember, I don’t remember just now,” adding to this con-
stantly confabulations.
Q. How old are you?
A. “I shall be 30”; (at other times) “I don't remember just
now. . . the papers have it no more. At times I will go up in
the direction when they call me.” (At other times) “I will be 30
or 20, I will say so too, I said I don’t remember anything.”
Q. But do you not know, on the contrary, that you are 67?
A. “Sixty-seven? no, I must be less; even there in San Ro-
mano so many times those young lads have called me . . . I
know those lads . . . I wish to know no more of them.”
Q. Then how old are you?
A. I haven’t passed 40.
Q. How old did I tell you you are?
A. I do not remember.
Q. Whose daughter are you?
A. I do not remember any more; of one a once mean .
Q. Have you ever seen your father?
A. He came once; I told him to go away; what is there to
come for?
Q. Then you know your father?
A. Why I have never spoken to him.
Q. Have your father and mother come to see you?
A. A few times . . . sometimes they came.
Q. What is your occupation?
A. I tend the cows, the sheep, also the stalls where the ani-
mals are kept . . . I clean; (at other times) I had as many trades
too in Livorno.
. Do you know what month it is?
Really I don’t know.
. Is it May?
Yes it will be.
. What month did I say it was?
. Oh, I don’t remember that.
;
I88
She seems continually busy as if she were still overseer of
the infirmary. When not restrained or led away, she goes to do
the cleaning in the water section so that it is continually necessary
to drag her away from it; she searches for the key which she says
she has lost, and starts to remake the beds already made. She
also has the habit of collecting things; she occupies herself in the
garden for long periods of the day in gathering small stones upon
a bench and suddenly throws them away when the physician sees
her. \
A few days before death, she became suddenly taciturn, did
not reply to questions and remained often motionless. She became
weaker without presenting a high fever, and died after three days,
on the 28th of January, IQ09.
IV
(Perusini's Case II.)
R. M., a basket maker, 45 years old, was admitted to the
psychiatric clinic (Munich) Sept. 21, 1907.
A brother was not quite right. The patient himself was al-
ways sickly. He had never drank much and denied luetic infec-
tion. He is the father of three healthy children and his wife had
never miscarried. About ten years ago he had an inflammatory
skin disease. Since 1899 a change in him has been noticed: he
couldn’t work, claiming that he could not see. He forgot easily
—when he laid his tools down he could not find them a few min-
utes later and he would scold the children, charging that they had
taken them away. He became easily irritated by small matters;
was noisy and cried out; would bang his head against the wall
or bed-post and of late could do nothing, for when he began
anything he soon became confused and got things mixed. For
some little time he could not retain his urine and he miscurated in-
discriminately in the room or in his socks. There were never
any convulsions with loss of consciousness, but in the last few
days there had been frequent cramps in the hands and feet. He
would often say, “I can not eat, better I went in the water and
at least leave you alone.” He made many complaints.
Sept. 21, 1907. Small; poorly nourished; and looks his age
(45). Internal organs negative for pathological findings. Patel-
lar reflexes active; sensibility intact; pupils very narrow and react
very sluggishly to light and accommodation. Coarse tremor
of the hands; tongue muscles without tremor. Speech is
drawling with noticeable articulatory disturbance; complete dis-
orientation for place and time. Reckoning ability is very poor:
2x6=14, 3x6=— “I must write that down again, I am as stupid
as an ox.” What is the name of the German Emperor? “I can't
189
recall his name.” Who is Prince Regent of Bavaria? “Leopold.”
A number of three figures given him to remember he could not
recall a half minute later. He stated that for a year he had not
been able to work for the reason that he got things mixed. With
reading and writing tests he was put to his wits' end. “If you
gave me a thousand marks I couldn’t write.” He had never
heard voices, nor had ideas of influence.
Oct. 9, 1907. Marked apprehension. He sees the devil in
the corner; prays aloud and hides himself under the bed-clothing.
Oct. 25, 1907. Continues apprehensive; is depressed and
cries frequently.
Oct. 30, 1907. Could not name objects: Ring—“That is
something to stick in, I don’t remember what it is—a glove,”
He could not state the total value of a few small coins.
Nov. II, 1907. Continuous marked apprehension. He hides
himself under the bed cover and is abusive in speech. He fol-
lows the physician through the ward and tries to go out with
him; sees the devil standing in the corner. He continues mem-
tally accessible, but is disoriented for time and place. He com-
plains of difficulty in thinking and that he can remember nothing.
Handwriting is ataxic, with letters left out or misplaced, and
quite illegible.
No increase of cells in the cerebro-spinal fluid (3 cells per
omm.). In the examinatio nof the blood serum, no complement
deviation. Pulse pressure 90—IO5.
Nov. 18, 1907. No change; continues apprehensive. Trans-
ferred to Eglfing hospital.
Nov. 21, 1907. Continuous apprehension; is confused. He
walks the ward for hours at a time; unable to find his bed; often
refuses food and is untidy.
Nov. 22, 1907. Smears himself with feces and evidences n
sense of shame. te
Nov. 30, 1907. Scarely answers any questions; makes many
complaints and is completely disoriented.
Jan. I4, 1908. Epileptiform convulsions with initial outcry,
tonic and clonic spasms. *
March 27, 1908. A little accessible mentally. He hides him-
self under the bed cover. Rapid physical failing.
April 3, 1908. Exitus letalis.
V
(Perusini's Case III.)
B. A., a woman, 65 years old, was admitted to the psychiatric
clinic (Munich), March 9, 1907.
A sister was insane. The patient herself had always been
I90
tº w
l
well. She had been married but never had children and no
miscarriages. For I5 years she had suffered from an edema
of the legs. Since the death of her husband 15 years ago, she had
Successfully conducted an establishment for the manufacture of
liqueurs. For the last three years, as the result of her mental affec-
tion, she had been despondent. The present condition is said to
be of recent origin. She has had no apoplectic attacks, no at-
tacks of dizziness. Gradually her memory has weakened, com-
prehension failed and she has given away many of her belongings.
She became disoriented for time and place; had no grasp on
her surroundings; appeared confused; and of late had been ex-
cited. She talked a great deal and cried out loudly.
March 9, 1907. She looks her age (65), is remarkably small,
presenting a broad nose with sunken bridge, very thin face, scant
hair, short thick fingers and a somewhat cretin appearance.
Pupils react to light, though sluggishly; accommodation tests can
not be carried out. Patellar reflexes are present. The lower legs
are markedly swollen, of the nature of an elephantiasis. She
can walk only with difficulty; exhibits, however, no evidence of
paralysis. The heart’s action is regular. On account of extreme
resistiveness a complete examination is impossible. The urine
contains a trace of albumin. She is very active, elated and eupho-
ric. Speech content as follows: “Gutele, Memele, Mutele, ja gute,
Mamele, Mutele, ja so schon, so schonele.” Other than this no-
thing is to be gotten from her. To all questions she repeats the
above quoted words. Likewise when objects are given her to
name she always says “Gutele, schonele.”
March Io. It was determined, by various means, that she
could hear and understand what was said to her. In contra-
distinction, however, she employed in speech only a few para-
phasic words, e. g., “Schuntzer” for Taschentuch and the ever
recurring “Mutele, Mamele, Mutele, Gutele.” At times she made
characteristic Smacking noises with the lips and wafted kisses to
the physician. It was necessary to feed her, but to this she
offered no resistance.
March 15. Under rest in bed and diuretic medicaments the
edema has diminished considerably. A mild bronchitis.
March 21. Sleeps a great deal, even in the day time. No
mental change. The speech content is the same as noted above.
Transferred to Eglfing. *.
March 22. Pronounced silly euphoria. Prattles the same
words constantly. *
March 22. Fever; is unconscious. Consolidation of poste-
rior inferior portion of left lung.
March 24. Exitus letalis.
191
VI
(Barrett's case.)
“E. T. Until he was 48 there had been no mental disturb-
ance. At this age he complained of not feeling well and con-
Sulted a physician. The nature of this trouble is not known.
When he was 50 it was observed that he would give “foolish”
and incorrect replies during conversation. “When asked to do
Something he would not know how to go at it.” Five years later
the disturbance had become more marked. He became unable to
write. He frequently lost things. He would sometimes ask for
objects which lay directly before him. In talking he often used
the wrong words, and after he was 67 it became impossible to un-
derstand his conversation. At 68 he became a patient in the
Michigan Asylum at Kalamazoo. The physical examination at
that time showed marked arterio-sclerosis and irregular heart
rhythm. Neurologically there was slight asymmetry of the face;
Romberg Symptom; staggering gait; the tongue was tremulous
and deviated to the right; the pupillary reactions were sluggish;
the knee jerks unequally exaggerated and there was slight ankle
clonus on both sides; there were no peripheral abnormalities of
the eyes, except arcus senilis, but it was noted that he appeared
as if blind; when asked to name objects he always felt for them.
There were many aphasic Symptoms. He had difficulty in un-
derstanding questions and many of his replies were unintelligible.
From the time he came into the hospital he was noisy and restless.
He was fed mechanically. He developed a slight febrile tem-
perature with a slow pulse. He became soporous; his head was
much retracted and eight days after admission died in coma.”
VII
(Alzheimer's second case.)
Johann F., 56 years old, a day laborer, was admitted to the
psychiatric clinic (Munich), Nov. I2, 1907.
Patient was a moderate drinker. Two years previously his
wife had died, since which time he had been quiet and dull.
For the last half year he had been forgetful; lost his way easily;
could either not perform simple tasks or executed them awk-
wardly; stood about in an aimless manner; took little interest in
his food but ate ravenously whatever was placed before him;
could not make even a simple purchase; and no longer bathed.
Sent by the overseers of the poor.
Nov. I4, 1907. Pupillary reactions normal. Patellar re-
flexes rather active; no paralyses. Speech was remarkably slow
but without articulatory disturbance. He was dull, slightly eu-
phoric and comprehended poorly. He frequently repeated the
I92
questions asked him instead of giving answers, often repeating
them over and over again. He could reckon the simplest math-
ematical examples only after long mental effort.
When asked to point out different portions of the body there
was frequent perseveration. Immediately after speaking of the
knee-cap, a key was called a knee-cap, likewise a match-box
which was also rubbed on the knee when asked what one did
with such a thing. He did the same with a piece of soap. Other
requests such as lock the door and wash the hands were correctly
complied with, although slowly and in a clumsy manner.
Sept. 20, 1907. To the question “What color is blood?” he
answered “Red.” Snow? “White.” Milk? “Good.” Soot?...—
He counted correctly up to ten, could name the days of the
week, give the names of the months and repeat half of the Lord's
Prayer, but could go no further. 2 x 2 = 4, 2 x 3 = 6, 6 x 6
= 6. He could tell the time of day by the watch, and button his
coat correctly. Given a cigar he placed it in his mouth, struck
a match, lighted the cigar and smoked, all of which he did in a
proper manner. Given coins to identify he examined them from
all sides then said: “That is, that is, we have here, here, here—.”
He could not name a match-box. He knew the use of a mouth har-
monica, a dinner bell and a purse, but he could not name these
objects. From a number of objects placed before him he could
pick out a match-box and a lamp, but failed when requested to
select a brush and a corkscrew. Requested to bend a knee he
doubled a fist. There was no impairment of ability to repeat words
after examiner.
How many legs has a calf? “Four.” A man? “Two.” Where
does a fish live—in the woods on the trees? “In the woods on the
trees.”
Lumbar puncture: No cellular increase; no complement de-
viation in blood or in cerebro-spinal fluid.
Eyegrounds: Ill-defined boundaries of the right papilla; left
eye normal findings.”
Sept. 23, 1907. Gets up and urinates near the bed.
Oct. 8, 1907. When asked to write he did not take a pencil,
but a match-box, with which he attempted to carry out the request.
The focal symptoms show a great variation in their intensity.
Nov. 15, 1907. Elated; laughs much; eats a great deal; sits
around stupidly, but actively moving his hands, pulling his blouse
or nightcap apart; at times tearing everything in the way of bed
linen or clothing and cramming the pieces into his mouth.
He is still able to repeat words after examiner. Objects are
used incorrectly, e. g., brushes his coat with a comb. When given
a key and told to unlock the door he goes to the door but ap-
I93
parently doesn’t know what to do. In writing his name he re-
peats letters. He could not be gotten to write anything other than
his name.
When objects are pointed out to him to name he makes no
answer or repeats senselessly the request, doing so at times Over
and over again. He makes no spontaneous utterances. If one
irritates him by taking away the towel which he is chewing he
soºn etimes becomes violent.
When he was asked to make certain movements with the
hands he repeated the words of the request. When the move-
ments were made before him he looked on as though not com-
prehending. Asked to place the thumb with outstretched fingers
to the tip of the nose—“thumb the nose” (Langenase)—he thumbs
the chin instead; to throw a kiss he holds the hand in a rather
constrained manner as though making a military Salute, never-
theless brings the hand to the mouth.
Dec. 8, 1907. Manifest deterioration. He gets out of bed
frequently; busied with his bed things.
Wassermann reaction negative in blood and cerebro-spinal
fluid. One cell in a c.mm. of cerebro-spinal fluid.
March 2, 1908. Told to wash his hands he does so correctly,
but continues washing them indefinitely and when told to turn off
the faucet holds his hands beneath it. Asked to seal a letter he
attempts to light the candle with the stamping die, later warms
the wax and presses it on the die. Given a cigar to light he rubs
it on a match-box.
March 4, 1908. He is restless and imparts the impression
that he is delirious. Constantly packs his bed clothing in a bun-
dle and will leave, doing this the entire day with perspiration
streaming down his face. He is now constantly resistive, com-
plying with no requests. When given a hair brush he licks it.
Almost no spontaneous speech.
May 5, 1908. Other patients have taught him to sing “Wir
sitzen so frohlich beisammen.” but he has to be frequently prompted
with the words, although the melody is carried fairly well.
May 12, 1908. A physical examination shows no pathologi-
cal alterations in the pupils or tendon reflexes. The papillae of the
eyegrounds are noted as normal. (Right papillae somewhat ab-
normally formed.) When questioned he usually answers “yes”
and then laughs in a demented manner. He can still repeat after
examiner, at times exhibiting a perseveration in so doing. Cer-
tain movements such as spreading or twisting the fingers he imi-
tates correctly, though awkwardly.
June 12, 1908. He goes for a walk in the garden. So long
as anyone accompanies him he does not stop, going at a rapid
I94
gait with the perspiration streaming from him, constantly waving
the tail of his coat which he grasps firmly. When in bed he is
constantly waving the bed clothing about, grasping them firmly
in the meanwhile. When he was pricked with a pin or the soles
of his feet tickled, for a long time he did not react, but finally
Struck at the physician. He scarcely speaks a word now.
It is remarkable, nevertheless, that in spite of his pronounced
dementia there is no disturbance of ability to execute gross move-
ments, nor is there noticeable ataxia or weakness in the extrem-
ities.
Dec. I4, 1908. Passes feces and urine regardless of where he
may be ; no longer talks; always busied with his bedding or
blouse. When another person begins, he still sings “Wir sitzen
so fråhlich beisammen.”
Feb. 3, 1909. An epileptiform attack of a few minutes’ dura-
tion; twitchings in face.
Feb. 6, 1909. Right facial weakening.
Feb. 9, 1909. Disappearance of facialis phenomena. Re-ex-
amination of the blood and cerebro-spinal fluid gave the same
negative result as formerly. He is very resistive to whatever is
done for him; constantly busied with bed-cover or with his
blouse; no longer speaks or complies with requests.
May 31, 1910. He has lost slowly but steadly in weight.
Always busy in the same manner with the bed-clothing.
July 29, 1910. Epileptiform convulsions of two minutes’ dura-
tion.
Sept. I, I91O. Rise of temperature to 38.5 C.; crepitant rāles
over the lungs.
Oct. 3, 1910. Death from symptoms of pneumonia.
VIII
(Bielschowsky’s case.)
Mrs. B. became ill at the age of 58. From information fur-
nished by relatives, a gradual change was noted, following the
death of an only son. She was very forgetful, lost her grip on
the management of her household and finally was unable to per-
form the simplest housework. There had never been periods of
excitement. To be sure, the information furnished by friends
was not as full as might be and was rather untrustworthy. There
was no apoplexy throughout the entire course.
Admission to Gitschner Street Hospital (Berlin) was not
until two years after the onset of the malady. Physically the patient
offered no symptoms worthy of note. The pupils were of average
diameter and reacted promptly to light and convergence. The eye
grounds were normal. Motility and sensibility of the extremities
I95
were shown by repeated examinations to be undisturbed. The
gait was cumbersome and slow but revealed no paralytic disturb-
ances. Patellar and tendo Achillis reflexes were active; no Babin-
ski; negative Wassermann reaction.
The mental condition was that of an advanced dementia.
Especially striking were the extreme memory impairment and
disturbance of retention. She did not remember the most im-
portant events in her life. Her vocabulary was very limited.
On many days she replied to questions only with “yes” and “no,”
but she could correctly repeat words after examiner. In these
tests there was frequently a perseveration of the last spoken
word. Objects placed before her she does not name spontaneously.
Still when pictures are shown, the wrong name given to a picture
is immediately detected. &
When requested to imitate with the arm or leg certain simple
movements she generally succeeds, nevertheless, in an awkward
manner. With complicated tests she fails completely. Instead
of winking the eyes or making threatening movements as re-
quested, she scratches the bed cover. Requested to strike a match,
the movements are inappropriate. How well she understood
the requests could not be determined with certainty, but from the
anxious facial expression and embarrassed behavior it was evi-
dent that the patient was conscious of her defect.
During her stay in hospital no noteworthy change developed.
After about four weeks she became very apathetic and then
passed into a comatose state, during which she died.
IX
(Lafora's case.) *
William C. F., a veteran of the Civil War, was admitted to
Gov't. Hospital for Insane, Washington, D. C., when 58.
After the war the patient was very much exhausted. Later
and for many years, he had been employed as a bill-poster. He
was a heavy drinker.
His present illness began in Nov., 1906, at the age of 56. He
evidenced persecutory delusions; was excited; incoherent; and de-
manded protection. Some weeks before this he had made mar-
riage advances to several nurses. Soon after the onset of his ill-
ness he became untidy with bowel and bladder movements and
would smear his face and body with feces. Once, during an ex-
cited period, he threw an iron bar at an attendant. He was al-
ways markedly disoriented, could not give the name of his
physician or nurses, nor tell where he was. Often he could not
find the way to his room.
Sept., 1907. He attempted to run away. At this time he
was more careful in dress and generally more cleanly.
I96
During the further course of his illness there were transitory
periods of excitement and confusion. Several times he attempted
to escape from the hospital. Disturbance of retention appeared
early.
Jan., 1908. He could no longer find his way to bed or his
place in the dining room.
Sept. 23, 1908. Attacks of dizziness from which he recovered
on the following day.
Oct., 1908. He kept to his bed and frequently refused food.
Echolalia and long-continued perseveration were often observed.
Sleep was always good. He took no interest in his surroundings;
often talked and laughed to himself. Dementia, disorientation,
indiscriminate bladder and bowel movements and untidiness were
progressively worse.
Jan., 1910. A urinalysis revealed albumin and granular casts.
March, 1910. He often ate his excrement. Sometimes he
was depressed, sometimes excited. To this period belongs the
following dialogue between the patient and nurse:
What day is it? “I don’t know, ma'am.”
What date is it? “I don’t know that, miss, man, Mr.”
What month and year? “Right under this corner, Mr., man.”
How long have you been in this hospital? “Right there, miss,
is all that I know, I tell you.”
What kind of a place is this? “I don’t know, I know noth-
ing, absolutely nothing, nothing, nothing, nothing.”
Where is it? “Hell, hell, hell, hell, hell, hell, hell, hell, hell.”
Where did you come from? “I have already told you. I was
in Lancaster; I don’t know anything.”
Patient then said he heard a beautiful lady speaking to him.
What did she say to you? “I don't know whether I told you
or should; it is fine, fine, beautiful, beautiful.”
Later, he again frequently ate his excrement; was untidy;
disturbed his clothing; moved about in an aimless manner or re-
mained the entire day in bed.
Jan., 1911. He had to be fed. Occasionally he disturbed the
linoleum on the floor and would chew it vigorously.
Feb., 1911. Very feeble; dementia progressing rapidly.
March, 1911. He received a violent blow from another
patient, nevertheless after a few days his appetite was again good
and he seemed to feel well.
March 13, 1911. Anuria, which continued with slowing res-
pirations, cyanosis, inability to swallow, and unconsciousness until
death, March I4.
X
(Westborough State Hospital case, vide supra.)
I97
XI
(Betts’ case.*)
“C.F., female, milliner, 55 years, United States, single, some-
what intemperate. Admitted May 23, 1901. (Buffalo State Hos-
pital, N. Y.) Onset somewhat indefinite at about 40 years, with
marked memory defect and disorientation, with mild simple de-
pression. During her first four years’ residence she merely showed
extremely defective memory for both recent and remote past,
then gradually became untidy and restless, resembling a case of
general paresis. A note made January, 1905, states: “Memory de-
fect very marked; speech rambling and ataxic. Test phrases very
poorly handled; writing tremulous and almost illegible. Station
steady; knee jerks normal. Marked tremor of hands, tongue and
facial muscles. Pupils slightly unequal but react well to light and
accommodation. A few months later she became very filthy and
destructive in habits. Was quite disoriented, very restless and
resistive. She showed progressive physical failure and in October
I908, a diagnosis of pulmonary tuberculosis was established.
During the last few months of her illness she showed great tremor
and resistiveness. Died Oct. 31, 1908.”
XII
(Schnitzler's case.)
Mrs. Van D., aged 34, was first admitted to the Polyclinic
(Utrecht) Dec. Io, 1908.
From her physician and husband the following anamnesis
was obtained: Formerly the patient was always well. She had
been married nine years. Early after marriage, the husband states,
she gave evidence of not being up to the average mentally,
“somewhat stupid,” otherwise she was an orderly housewife, the
household carefully looked after, and she displayed an interest in
the little gift shop which her husband conducted. She did not use
alcohol. Of four children borne two are living and well, the other
two died at the ages of three months and three days respectively.
There had been no miscarriages. The last child was premature
(seven months). Menses regular.
After the last parturition her husband reported that she was
quieter than usual, often sat unemployed, slept a great deal and
on the slightest pretext would revert to the loss of her child.
In short, her condition was one of tearfulness and somnolency.
The onset of the disease dated back 2–3 years. The indolence
noted grew worse gradually, besides, she took on flesh rapidly—
* In reply to a letter of inquiry concerning this case, Dr. Betts writes: “In regard to
aphasic symptoms there is no note made in clinical history except that the writing was
practically illegible. Anatomically the cortex showed a very considerable number of
plaques and Alzheimer degeneration was very marked and extensive.”
198
“grew thick in face and body.” As the disease progressed
she showed less and less interest in her surroundings, was untidy,
could sleep through the entire day, spoke but little, acted in a
childish manner—laughing at everything—and neglected the chil-
dren—allowed them their way in everything. Her appetite was
always good. In the management of her household she gradually
became incompetent; at first she could do simple cooking, but
finally even this was impossible; she would either leave the stove
door Open, or allow the food to burn, or forget to add water, etc.
Finally she became “like a little child.” Often when she had
made a mistake she realized what she had done. There were
never any excited episodes or anxious states.
Status pracsens.—On admission to the clinic the patient was
remarkably Stout. The face appeared bloated, the skin of face
on palpation felt somewhat myxedematous, on the forehead fine,
closely applied wrinkles. The trunk was plump, disfigured by
heavy folds of the skin, the arms and legs formless masses. The
skin was everywhere thickened and pitted on pressure. The
hands were the least swollen, the distal phalanges somewhat
pointed. The color of the skin was not pale but a diffuse rose
color. The growth of hair was not heavy; the nails showed
nothing abnormal; many carious teeth. Body weight Ioo kg.
The patient spoke slowly, now and then somewhat faster.
One got the impression that she required for her answers a
rather long reaction time, although when once started she was
more fluent. Movements were correctly executed but a long time
was required before she attempted them.
A small, somewhat hardened thyroid gland—surgically oper-
able—was palpable. The heart was somewhat enlarged; urine
negative for albumin and sugar. Temperature normal; pulse 90-
IOO.
The patient appeared to the other patients as abnormal, she
was continually somnolent. The right hallux was permanently
in Friederich's position. No further physical symptoms noted.
Eyegrounds normal. The patient laughed in a childish manner
at everything that happened about her. She wanted to go home,
and several times ran out of the ward; wanted to visit her rela-
tives but was easily pacified when told that she couldn't, never-
theless she went all the while to the door. Otherwise she gave
no trouble to the nurses.
Dec. 17, 1908. Test for calculation ability.
5 x 6 = 30 in 2 Seconds.
I5 x 3 = 49, 45, in 7 Seconds.
12 x 7 = 48 in 6 seconds.
I4 x 3 = 42 in 21% seconds.
I99
I7 x 4 =68 in 24% seconds (reckons 4 x IO = 40, 4 x 7
== 28, 68).
I2 x 8 = 96 in 4% Seconds.
18 x 3 = 54 in 9% seconds.
I6 x 7 = (reckons 7 x IO = 70, 7 x 6 = 42 does not add
together).
2I x II = after I2 minutes, “I can’t reckon so fast.”
Counts from I–50 correctly in 27 seconds. From 50—I, leav-
ing out 22, in 62 seconds.
Repeats the names of the months faultlessly in 5% seconds;
counts I–2O in 5% seconds, from 20—I correctly in Io seconds.
Examination with Heilbronner's pictures.
Lamp.
I. Don’t know.
2. Don’t know.
3. Lamp, it is always the same.
4. Also a lamp.
Church.
I. Church with steeple.
2. (What goes with it?) Points out approximately correctly.
3. (What goes with it?) Points out.
4. (What goes with it?) Points out.
5. (What goes with it?) Points out +. Says, The little house,
the things (are the windows).
6. (What goes with it?) Points out +.
7. (What goes with it?) Points out +.
8. (What goes with it?) It's the same.
Fir tree.
I. Fir tree.
2. (What goes with it?) Don’t know.
3. (What goes with it?) Points out.
Cannon.
I. Don’t know.
2. The same thing with a star in it.
3. The same don’t know what it is, but differentiates it from
something else.
Wheelbarrow.
I. Don’t know.
2. Don’t know; differentiates +.
3. Wheelbarrow.
4. Differentiates +.
5. Differentiates +.
Boat.
I. Don’t know.
2. Don't know; differentiates +.
2OO
3. Don’t know; differentiates +.
4. Don’t know; differentiates +.
5. Boat. -
The patient answers quickly, the examination interests her
(observations noted by others, not defective, just as patients in
every detailed aphasic examinations are designated as childish),
she always wants to look at the next following picture and turn
the leaves of the book herself.
She was shown weather forecasts cut from a newspaper (The
Telegraph) such as, man with an umbrella or a lady with a sun-
shade, and the like, printed above The Telegraph's forecasts for
the day. The patient looks at the picture, “A man with an um-
brella,” she says. At first she reads the printed matter in a verbal,
paraphasic manner, then correctly. The pictures are all alike,
“From a leaf calendar,” she adds spontaneously, “are they not?”
(Do you know The Telegraph?) “Yes, there is a newspaper
called The Telegraph and there is a telegraph where one may send
messages.”
“Yes, the pictures are from the newspaper.”
(What is that there?) Reads the print in a low tone; “That
is on all of them.”
(What indicates rain?) “The man with the umbrella.”
She then reads a notice from the paper without a mistake.
The general impression is won that, along with the retardation,
there is a defect; the dementia, however, is manifestly not great,
not sufficient to offer an explanation for the totality of her symp-
tomS.
With the Bourdon test—underlining certain letters in a read-
ing test—the results in general are poor; certain portions, how-
ever, are faultless.
Dec. 18, 1908, the patient was exhibited before the medical
society by an assistant of the surgical clinic, where she ran out of
the waiting room, necessitating the sister's running to the end of
the corridor after her. She wanted to visit her relatives. She
sat on a chair, frequently asleep during the demonstration, her
movements very slow.
Dec. 19, 1908. She knew that she had been in a large hospital
the day before, which reminded her of a theater, though it was
not; that many gentlemen were seated there and that she was
somewhat anxious. She remembered sitting on a chair, and that
the assistant was there; that one of the gentlemen had spoken—
the professor (incorrect); that he had said that she had grown
stout in the last Io years and that she was 45 (correct) and that
she had corrected him as to her age. She was very positive that
it was the professor who had spoken.
2OI
Who showed you the pictures? “I don’t know.”
What was shown you? “I don’t know.”
Did you look in a book? “No.”
A small black book? “No.”
With pictures? “Oh, yes.”
What were the pictures in it? “I don’t know now.”
Animals or the like? “A wheelbarrow.”
And houses? “Yes.”
What kind of houses? “A house with a tower.”
Dec. 28, 1908. Since admission the patient has lost 2.2 kg;
for the last IO days she had been taking desiccated thyroid gland, one
dose a day.
She did not remember that during the first days of her hospital
residence she continually wanted to leave. Her face was less
bloated and she slept less, although by 7 p. m. she was ready for
bed. Simple examples she reckoned readily. She thought the
other patients made fun of her size.
After three thyroid tablets daily had been administered, her
weight reduced by 5 kg. and perhaps less retarded, she was dis-
charged Jan. 6, 1909, cautioned to continue the thyroid treatment
and to return for observation.
In spite of our advised treatment, the mental condition grad-
ually grew worse and at the suggestion of her physician she was
again admitted to the clinic, April 13, IQIO.
On this admission : No hemianopsia, bitemporal or otherwise;
lateral movements of eyes coordinated; no nystagmus. The eye-
lids could not be widely separated; they were swollen. There
were transitory indications of right facial paresis without involve-
ment of the frontal muscle. The pupils were equal and circular,
reacted to light and convergence. Ophthalmoscopic examination
revealed no abnormalities; plantar reflexes normal.
In walking her movements were rather clumsy, still without
characteristic gait disturbances; the right hallux always in Babin-
ski position. Speech was slow and there was difficulty in pro-
nunciation. She answered correctly simple questions, such as
“When did you come here?” “Do you know me?” etc., and she
counted the number of keys on a ring. She had no pain. She
ran to the door, wanting to leave. The skin was dry and ex-
tremely thick; on the back, blue marks. Lying in bed drinking
a glass of water, the water would run down her chin on her
clothes. Swallowing was difficult.
She repeated correctly 555,666 and Spoorwegmaatschappy, but
with a slight tremor of the voice. She counted correctly from
I—2O in 18 seconds, from 20–1 in 60 seconds but it was necessary
to stimulate her frequently. With this there was a slight tremor of
2O2
the legs. The examination established no evidence of aphasia, the
special examinations for signs of apraxia (raise the hands
aloft, point above with the index finger, grind coffee, wink the
eyes, make threatening movements) also gave negative results.
The threatening movements she accompanied with a dreadful
TO2.1".
April 25, 191O. Elevation of temperature with symptoms of
pneumonia; marked somnolency. She lay abed with mouth opened
and double ptosis. When the lips were touched, reflex closing of
the mouth. Swallowing was difficult. After many repetitions she
undoubtedly understood what was said to her. Reactive move-
ments were carried out slowly and incompletely. Of neurological
symptoms there was a distinct paresis of the fingers of the left
hand. The finger movements of the right hand and the toes of
each foot were unaffected. Besides, there was indication of hand
clonus on the left side. There was no hypotonicity of the extrem-
ities.
For a few days following, the clinical symptoms on the whole
showed no change. The attempts to speak gave one the impres-
sion of a patient suffering severe bulbar disturbance, only a vocal
tone produced.
April 20, 1910. She recognized objects with left hand without
much manipulation. The finger movements of the right hand
and the movements of the toes undisturbed. The ptosis of the
left eye was less pronounced. The temperature inclined to normal.
April 22, 1910. She is incontinent, complains of pain in the
side (probably from lying) decubitus; deglutition bad, best with
semi-solids.
April 23, 1910. Temperature again elevated. General con-
dition as noted above. No change in neurological symptoms.
Death.
XIII
(Jansens’ Case.)
A woman of 55 was admitted to hospital (Endegeest, near
Leyden) March 2, 1907.
According to information furnished by the family and her
playsician, she gradually became so demented, following a delir-
ium of several days’ duration two years ago, that not only was she
unable to manage her household affairs, but she herself had to be
constantly watched over and cared for. During the last few
months she had talked but little. One morning six months before
admission, she was unable to get out of bed, the right leg and
right arm were paralyzed. The paralysis, however, soon disap-
peared, but since then the mental symptoms had grown much
worse; the dementia had become more pronounced and She spoke
2O3
almost never. Of late she had repeatedly assaulted her daughter,
and above all she had been very restless. The husband further
reported that formerly his wife was cheerful and robust, but
always a bit obtuse; that she could neither read nor write. Hered-
itary factors were wanting.
Upon her reception at Endegeest she was put to bed, but im-
mediately left it. She was very restless, went about aimlessly,
sat on the beds of other patients and busied herself with the bed
clothing after the manner of a senile dement. She expectorated
all about her and defecated on the floor.
The most striking symptoms, however, was a characteristic
speech disturbance which showed itself in spontaneous as well as
in reactive speech. For hours at a time she would utter in a
monotonous tone “puk, puk, puk.” This perseveration appeared
more clearly in the form of a definite word-spasm (Logoklonie)
in her answers to questions. Requested to name a key which was
held before her she said: “that is then, then, then then” and to
the question “How old are you?” “Das weiss ich ni, ni, ni, ni, ni.”
To many questions there were no answers or any other kind of
reaction; reactions came only after a long while and after many
repetitions of the questions. During the first few days, a short
properly constructed sentence was occasionally heard in spon-
taneous as well as in reactive speech, but even these soon ceased,
only such expressions as noted above remained.
During the early part of her hospital residence she executed
command movements sometimes well, sometimes poorly, and in
general the simpler movements much better than the more com-
plex, but it was not long before such reactions also failed. Still
she was so very restless, continually leaving her bed, that it was
necessary to care for her in the continuous bath. She often sat
half-upright calling out rather quickly, for hours at a time, “ti, ti,
ti, ti,” meanwhile clapping her hands. If she were asked questions
she took not the slightest notice. She displayed just a little in-
terest in her relatives, whom she apparently did not recognize.
On the other hand she now and then addressed the nurse as
“Grete,” the name of her daughter.
From the very beginning and throughout her stay at Ende-
geest she had to be fed by the nurse, and she was always untidy.
During the three years in hospital there were several epileptiform
attacks (four in all) which differed from ordinary epileptic
seizures by long after-periods of unconsciousness, periods last-
ing an hour.
Now if I mention that the pupils reacted; that definite focal
symptoms—aside from apractic, aphasic and asymbolic indica-
tions—were absent; that the reflexes were normal; that the heart
2O4.
was not enlarged; that the urine was free from albumin; and that
there were no evidences of peripheral arteriosclerosis; then I have
outlined the chief features of the disease-picture which this
woman presented. I must add only that, following an epilepti-
form attack, a transitory right facial paresis was observed.
In the early part of 1910 slight contractures of the lower ex-
tremities developed. Once, after a long period in the continuous
bath, slight muscular twitchings were observed which while more
pronounced on the right side of the body were also noted on the
left side.
March, 1910, the following note was made: “The attention of
the patient is difficult to gain; even when food is offered she
makes no effort to take it, nor opens the mouth when the spoon
is brought near. Of her own accord she frequently appears to
follow objects with her eyes, but it is almost impossible for any-
One to arouse her attention. If she is asked, while eating, “Do
you wish more?” or “Does it taste good?” an occasional “yes”
is heard. This “yes” is the only intelligible word uttered dur-
ing a period of three hours, and should it be interpreted as an act-
tial reaction, then, it is the only mental contact made. It is also
Striking how less frequently the remarkable expressions (ti, ti, ti,
ti, or puk, puk, puk) are heard which earlier were so loudly and
repeatedly emitted. The last few months she has emaciated
markedly.”
In May, IQIO, she died suddenly and unexpectedly, while the
nurse was fixing the food preparatory to feeding her.
As supplementary the following is added: Lumbar puncture
was negative, likewise a Wassermann reaction of the blood. Ex-
amination of the eyegrounds revealed nothing abnormal.
The autopsy on this case revealed a markedly atrophic cere-
brum, the atrophy diffuse in character. Focal lesions were found
nowhere. The Sulci gaped and the convolutions were small.
Here and there a slight clouding of the meninges was observed.
The larger vessels exhibited no signs of arteriosclerosis. The
brain weighed 900 grams. The cord was not preserved.
Microscopically, plaques were present in great number and
widely distributed in the cerebral cortex, in greatest number in
the temporal gyri, while stratigraphically most numerous in the
second and third lamiae. Plaques were not demonstrated in the
cerebellum and basal ganglia. Numerous corpora amylacea were
distributed throughout the cerebral cortex. Alzheimer degenera-
tion of ganglion cells was present. In the cortical vascular apparatus
occasional arteriosclerotic changes were observed, including calcare-
ous alterations of the vessel wall. An occasional lymph and
plasma cell infiltration was noted.
2O5
Janssens believes his case is an example of Alzheimer’s dis-
ease, a form of senile psychosis which must be reckoned as an
atypical senile dementia.
SUMMARY
Briefly, the clinical histories of these cases may be summarized
thus: About middle life or slightly past, with one exception in
early adult life beginning at the age of 32, memory defect, dis-
turbance of retention and general mental weakness set in and
progress to a marked dementia. The progress of the dementia
in Some of the cases has been slow, in others fairly rapid. As a
rule, early in the course of the affection aphasic disturbances—
verbal amnesia, Occasional paraphasia and jargon, impairment of
ability to comprehend spoken language, graphic disturbances,
verbal and literal perseveration—ideational apraxias and agnosias
develop, varying from time to time in severity but never as intense
or consistent as the speech disturbances and apraxias originating
from coarse focal lesions of the brain. Mental confusion, with
Some delirium, lack of bladder and rectal control without evidence
of limb paralyses, good preservation of gross muscular strength,
considerable motor activity and restlessness have been striking
features of the majority of the cases. Auditory and visual hal-
lucinations with apprehensive delusions based upon them and
spatial as well as temporal disorientation have been prominent
in some instances. Disturbances of the motor projection paths
were slight or absent; if occurring at all usually appeared late,
even then were often transitory. In a few of the cases motor
disturbances have been noted as residua of epileptiform convul-
sions. Convulsions with loss of consciousness, however, have
not been observed, save in the terminal stage, epileptiform attacks
and muscular twitchings being recorded. With exception of Case
II, luetic infection does not appear in the anamneses. Alcoholic
indulgence while noted as moderate in VII and X, pronounced
in II, IX an XI, absent in XII and not stated for the remaining
cases, seems to have played no rôle or at most a minor one. An
apathetic dementia was recorded for two of the cases (VIII and
XII) and skin alterations suggestive of myxedema in two cases
(V and XII). **
Gross Brain Anatomy.—Atrophy was noted macroscopically
as follows: general in I, XII and XIII, general with regional
emphasis in II (frontal and temporal), V (occipital lobes), IX
right Ammon's horn), XI (frontal and parietal), regional in
VII (frontal, parietal, temporal), VIII (frontal), X (frontal, left
temporal) and not mentioned for the remaining cases. A quite ap-
preciable cerebral arteriosclerosis, particularly of the larger ves-
2O6
sels of the base and their chief branches, was found in I* and X.
Slight arteriosclerotic change of these vessels in VII, moderate in
XI, and it was especially noted that spich change was wanting in
II, III, IV, V, VI, VIII, IX and XIII. No note was made in
XII. Gross focal lesions were not present in any of the cases save
II, in which an old cyst of the corpus callosum, a myelitic softening
with atrophy of left pyramidal and posterior columns in cervical
cord and a meningo-myelitic focus of the lumbar region were en-
countered. There was hyperplasia of the pia in I, II, III, IV, V,
VII, IX, X and XII, a slight thickening in frontal regions of VIII
and not mentioned for VI and XI.
Microscopical Findings.--The microscopical examinations of
the brains revealed a large number of miliary plaques in all of the
cases save XII. The plaques were more numerous and frequently
of greater size than those usually found in other brains exhibiting
these structures. In case VII they were of enormous proportions,
a single plaque extending in many instances through one or more
cortical laminae. In XII no plaques were found. The peculiar
basket-like alterations due to the presence of thick, darkly stain-
ing intracellular fibrils arranged in whorls or in a tangled mass,
have been found in all of the cases with exception of VII. For-
merly these neurofibril alterations in combination with plaques
were considered of great diagnostic significance for the mental
disorder under consideration, but the combination has been re-
ported by several observers [Fischer (12), Barrett (5), Sim-
chowicz (13), Fuller (9)] as present in brains of some typical
senile dements. The writer has also seen basket-cells in com-
bination with plaques in the case of a man of 80 dying without
psychosis. Bielschowsky has suggested that the coarse fibrils
one sees in cells so affected are perhaps the result, in part, of in-
crustations of neurofibrils with deposited products of patholog-
ical metabolism. He also points out that the course of these
fibrils is not always that of the usual course of the normal
neurofibrils and is inclined to consider them as entirely foreign
elements. Alzheimer conceives a degeneration and chemical al-
teration of the intracellular neurofibrils which permit them to be
stained by other methods which do not usually display these ele-
ments. Fischer (I2), who reports I9 cases showing such cells,
interprets these peculiar cell changes as coarse-fibered prolifera-
tions of neurofibrils. He does not consider his cases as examples
*In Alzheimer’s abstract of Case I, as originally published, the larger cerebral ar-
teries are reported as sclerotic. (“Die grosseren Hirngefässe sind arteriosklerotisch
verändert.” L. c., p. 147, 1906.) In Perusini’s report of the same, case the larger yes-
sels are stated to be without arteriosclerotic changes. (Die grossen Hirngefässe, der . . Cir-
culus arteriosu Willisi, die A. A. Sylviiusw.bieten keine-Zeichen einer deutlichen Arteriosklerose
dar: keine erheblichen regressiven Veranderungen der Gefässwand,” L. C., p. 301, 1909.)
2O7
of Alzheimer's disease, but places them in a group which he desig-
nates as presbyophrenic dementia. In addition to the changes
already noted complete destruction and disappearance of gangloin
cells have been reported, Nissl's chronic nerve cell changes and a
rich lipoid content of ganglion and glia cells. Progressive and
regressive alterations of the glia are rather generally reported,
and likewise progressive-regressive phenomena of the cortical
vessels; in IX, marked calcification of smaller vessels in Am-
mon's horn, and occasional calcareous changes in the cortex of
XIII. Infiltrative phenomena have failed in all cases except II,
in which there was 'a moderate infiltration of lymphocytes in
cortical vessels and pia, endothelial proliferation suggestive
of luetic endarteritis and occasional lymphocytes and plasma cell
infiltration in XIII.
From all that has preceded, it is reasonable to assume that the
type of cases which have been discussed, while not in every in-
stance free from sclerotic vascular alterations of the brain, is not
a type of mental disease resulting from arteriosclerosis. In a
certain sense a precocious senium is conceivable, but by this some-
thing quite different from an early arteriosclerosis is meant. In
an earlier paper I have argued that arteriosclerosis per se had
little or no causative relationship to the formation of miliary
plaques of the brain so characteristic in the miscroscopical find-
ings of the type of case here considered and in many cases of
typical senile dementia, although many brains of the latter class
showing plaques also exhibit considerable arteriosclerosis. On
the other hand, plaques may be wanting in brains exhibiting the
maximum of arteriosclerosis, particularly in cases recognized
clinically as arteriosclerotic insanity and post-apopletic dementia.
In all cases of Alzheimer’s disease reported, with one exception
(XII), plaques have been found in great number, but only two
of the cases have shown macroscopically any appreciable arterio-
sclerosis.
NOTE.
Since this paper was completed, November, 1911, Ziveri has published an
additional case (Su di un caso annoverabile nella cosidetta “malattia di
Alzheimer.” Rivista di Patologia nervosa e mentale, Anno XVII, fasc. 3,
pp. 137-148,) which though occurring in a subject of 65, presented the char-
acteristic clinical symptoms and anatomical findings which have been de-
scribed in the preceding cases.
REFERENCES.
I. Alzheimer. Ueber eigenartige Erkrankung der Hirnrinde. Allg. Zeit-
schr. f. Psych., Bd. 64, I46. (1906.)
2. Bonfiglio. Di speciali reperti in un caso di probabile sifilide cerebrale.
Riv. speriment, di freniatria, Vol. XXXIV, p. 196. (1908.) t
3. Sarteschi. All’ istologia patologia della presbiofrenia. Riv. speriment.
di freniatria, Vol. XXXV, p. 464. (1909.)
208
4. Perusini. Ueber klinisch und histologische Eigenartige Erkrankung
des späteren Lebensalters. Nissls u. Alzheimer's Arbeiten, Bd. 3,
p, 297. (1909.)
5. Barrett. Degeneration of Intracellular Neurofibrils with Miliary Gliosis
in Psychoses of the Senile Period. Proceedings Am. Medico-Psy-
cholog. Assoc., Vol. XVII, p. 393. (1910.)
6. Alzheimer. Ueber eigenartige Krankheitsfälle des späteren Alters. Zeit-
Schr. f. d. gesamte Neurol, u. Psych., B.J. 4, p. 356. (Feb., 1911.)
7. Bielschowsky. Zur Kenntnis der Alzheimerschen Krankheit (praseni-
len Demenz mit Herdsymptomen). Jour. Psychol. u. Neurol., B.J.
I8, Ergänzungsheft I, p. 273. (April, 1911.) *
8. Lafora. Beitrag zur Kentnis der Alzheimerschen Krankheit oder präs
enilen Demenz mit Herdsymptomen. Zeitschr. f. d. gesamte Neurol.
u. Psych., Bó. 6, p. 15. (July, 1911.) Eingegangen am 27 Mai, 1911.
9. Fuller. A Study of the Miliary Plaques in Brains of the Aged. Pro-
ceedings Am. Medico-Psycholog. Assoc., Vol. XVIII, (June, 1911.)
Io. Betts. On the Occurrence of Nodular Necroses (Drusen) in the Cere-
bral Cortex. , A Report of Twenty Positive Cases. Am. Jour. Insan-
ity, Vol LXVIII, p. 43. (July, 1911.)
II. Fischer. Die presbyophrene Demenz, deren anatomische Grundlage
zeit schr. f. d. gesante Neurol. u. Psych., Bol. 7, p. 34. (Sept., 1911.)
I2. Fischer. Die presbyophrene Demenz, deren anatomische Grundlage
und klinische Abgrenzung. Zeitschr. f. d. gesamte Neurol. u. Psych.,
Bd. 3, p. 371... (1910.) e e º 'º ºn tº $. º
I3. Simchowicz. Histologische Studien über die senile Demenz. Nissl u.
Alzheimer’s Arbeiten, Bd. 4, p. 365. (1910.)
14. Jansens. Ein Fall der Alzheimerschen Krankheit. Casuistischer Beit-
rag. Psych. en Neurol. Bladen, No. 4 en 5 (Juli-October, 1911.)
EXPLANATION OF PLATES.
FIG. I.-Right prefrontal cortex showing a rich deposit of miliary plaques.
FIG. 2.-Left Ammon's horn. More than a hundred plaques may be
counted.
FIG. 3.−Island in plexiform layer of left gyrus hippocampi. All gang-
lion cells showing Alzheimer degeneration.
FIG. 4.—Typical plaque, oil immersion lens. Alzheimer degeneration also
shown.
FIG. 5–Beginning glia encapsulation of plaque.
FIG. 6-Glia fibres penetrating plaque.
Figs. 1, 2, 3, 4 are from sections prepared, after the Bielschowsky silver
impregnation method, figures 5 and 6, Weigert’s method for neuroglia.
WESTBOROUGH STATE HOSPITAL PAPERS (Series I)
PLATE XXXV.
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º
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-
É

WESTBOROUGH STATE HOSPITAL PAPERS (Series I)
PLATE XXXVI.
º
-
- - - - - -
- - . - - -
- -
-



WESTBOROUGH
PLATE XXXVII.
STATE HOSPITAL
PAPERS (Series I)

WEST BOROUGH STATE HOSPITAL PAPERS (Series I)
PLATE XXXVIII.
6
FIG.

XIV
FURTHER OBSERVATIONS ON ALZHEIMER'S DISEASE.2%
BY SOLOMON. C. FULLER, M.D., AND HENRY I. KLOPP, M.D.
One of us has recently described what we believe to be the
tenth recorded case of so-called Alzheimer’s disease, that is,
certain histopathological alterations of the brain indicative of
senile involution associated with clinical symptoms such as are
exhibited in the severest form of senile dementia, but appearing in
Comparatively young persons. Included among the clinical symp-
toms are phenomena suggestive of coarse focal lesions of the
brain—aphasic and apractic disturbances—which have not been
accounted for by coarse focal lesions at autopsy.
For purposes of comparison there were added to the report
of the first Westborough case the clinical histories of all cases
then known to us, ten from foreign literature and two from Ameri-
can Sources, together with a critical analysis of these histories and
their associated anatomical findings. It was shown that despite cer-
tain basic chracteristics, more or less present in all of the cases,
essential differences existed which precluded for the present any
dogmatic statement as to the exact clinical grouping of these cases,
as well as any claim for a definite gross or histo-pathological
anatomy. Nevertheless, in so far as one may be justified in cor-
relating anatomical changes with clinical symptoms, there is much
in the finer anatomy as a whole to indicate a psychosis dependent
in a great degree upon involutional changes in the brain and blood
vascular apparatus, while the clinical histories offer many features
which we are accustomed to associate with senile mental dis-
orders.
The first case of Alzheimer’s disease to be recognized as such
at Westborough was clinically and anatomically quite comparable
to the first case reported by Alzheimer" and the group of cases
later collected and published by Perusini.” The case which forms
the subject of this communication did not exhibit anatomically the
peculiar type of intracellular neurofibril alteration common to the
majority of reported cases, and in this respect is like Alzheimer's
second case, the only other to our knowledge in which the basket-
like appearance of many ganglion cells was wanting. So-called
senile plaques, while present, were neither large nor numerous, and
differed slightly in structure from plaques as usually described, but
*Presented in abstract at the sixty-eighth annual meeting of the American Medico-
Psychological Association, Atlantic City, N. J., May 28-31, 1912, and printed here by
,courtesy of he Association.
2IO
exhibited among themselves a great degree of uniformity. More-
over, the mode of onset and much of the clinical course suggest
that certain exogenous toxic factors, which as a rule we do
not link with the exciting or even the predisposing causes of senile
psychoses are, perhaps, more frequently operative than has been
Supposed.
Before going on to the history of this case we quote from the
paper referred to above a brief summary of the leading clinical
features of all of the cases as revealed by the literature: “About
middle life or slightly past, with one exception where the onset
was in early adult life, memory defect, disturbance of retention
and general mental weakening set in and progress to a marked
dementia, in Some of the cases slowly, in others rapidly. Early
in the course of the affection aphasic disturbances—verbal
amnesia, occasional paraphasia and jargon, impairment of ability
to comprehend spoken language, graphic disturbances, verbal and
literal preservation—ideational apraxias and agnosia develop,
varying from time to time in severity but never as intense or con-
Sistent as the speech disturbances and apraxias originating from
coarse focal lesions of the brain. Mental confusion with some
delirium, lack of bladder and rectal control” without evidence of
limb paralyses, good preservation of gross muscular strength, con-
siderable motor activity and general restlessness have been strik-
ing features of the majority of the cases. Auditory and visual hal-
lucinations with apprehensive delusions based upon them and
spatial as well as temporal disorientation have been, in instances,
likewise characteristic. Disturbances of the motor projection
paths were slight or absent; if occurring at all usually appeared
late, even then were often transitory. In a few instances motor
disturbances have been noted as residua of epileptiform convul-
sions. Convulsions with loss of consciousness, with One excep-
tion,t have not been observed in the terminal stage, epilepti-
form attacks and muscular twitchings being recorded. With ex-
ception of Case II, luetic infection does not appear in the
anamneses. Alcoholic indulgence while mentioned as moderate in
Cases VI and VIII and pronounced in II and VII seems to have
played no role, or, at most, a minor one.”
So far as we are aware, these still remain the Salient clinical
featules of this type of cases. The Original aiiatolnical picture, on
the other hand, has undergone considerable modification, although
preset ºng he close kinship with the histo-pat'lo'ogical alterations
of senile cerebral involution. The anatomical changes of this
*Not necessarily the result of paralyses, but rather the untidiness that is commonly
associated with confused states and marked dementia.
fThe case here reported is also an exception.
2II
atypical senile group together with what may reasonably serve as
a criterion for a senile psychosis will be discussed more in detail
in the further course of this paper.
The history of the second case of Alzheimer's disease to come
to autopsy at Westborough State Hospital is as follows:
No. 9879, a woman of fifty-six years was admitted to Westborough State
Hospital December Io, 1911, on a transfer from the Arlington Health Resort,
a private institution for nervous and mental diseases, where she had been a
patient since August 8, 1911.
It is reported that throughout life the patient had been of the so-called
nervous temperament—quick and sensitive—but until the present illness had
usually exercised good self-control. In 1883, while descending a flight of
Stone stairs she fell, striking the coccyx and has had soreness in that region
ever since. Some twenty-five years ago she received rather painful injuries
in an accident, she was thrown from a moving carriage, sustaining extensive
lacerations about the head, one of which nearly severed an ear, and was
dragged for a considerable distance over the granite paved blocks of the
street. She was unconscious for twenty-seven days after the accident, but no
history of paralysis, speech disturbance or amnesias following the occurrence
was elicited. During several years thereafter she suffered severe periodical
headaches at intervals of about three months, the attacks lasting on an average
of three days and each leaving her quite exhausted physically. In about
three days after the cessation of the cephallagia she would regain her usual
health. These periodical headaches, however, had long since ceased. In 1909
she had an attack of broncho-pneumonia, said to have been of short duration
and from which she made a good recovery, her general health, save for habit-
ual constipation, remaining good until the onset of the present illness, in
May, 1911. At that time a particularly malignant streptococcic tonsilitis was
prevalent in Boston and its vicinity, a form of tonsilitis which often proved
fatal to infected persons over fifty. A son-in-law, in whose household the
patient lived, and his wife (her daughter) contracted the infection, and our
patient undertook their nursing, the care of a young grandchild and the
management of the household. After a short while she, too, developed a sorc
throat which, it appears, was of a milder. type. At any rate for the reason
of her many responsibilities, her friends state, she did not “give in to it,”
continuing to care for the sick members of the family and ordering the house-
hold affairs.
June 23, 1911, the son-in-law died as the result of the malignant tonsilitis.
Almost immediately thereafter the patient developed an articular rheumatism
affecting the legs, arms and hands. Even then she did not take to bed, for
she was very busy with preparations for changing the residence of the family,
most of the work devolving upon her since the daughter, though recuperating,
was still not strong. The arthritis persisted for about a month.
August 1, 1911, she was free from pains in the joints, but was in very
poor physical condition and was extremely nervous. For several weeks there
had been a progressive asthenia, rapid emaciation and marked insomnia. For
about a month, although retiring at a late hour, she could not sleep after
3 A.M., when, because of the restlessness engendered by the loss of sleep,
she would get up and begin the day's work at that hour. Meanwhile, in addi-
tion to rather vague and general apprehensions, she was particularly apprehen-
sive as to the future of her daughter and grandchild, now that their bread-
winner and natural protector was gone, an apprehension far in excess of the
normal. Always possessing a fear of hospitals of any nature whatever, this
feeling became accentuated. From her impaired physical condition she con-
cluded that a serious illness was imminent. There was also a sense of im-
pending death, for she frequently gave directions to her, daughter for the
disposition of her belongings in case anything happened to her.
August 3, 1911, certain disorders of , speech were noted, described by
friends as “peculiar.” On questioning the relatives it was learned that
2I2
these speech disturbances resolved themselves into irrelevancy, desultoriness,
hesitancy, as though groping for the proper words, and occasional paraphasia,
whereas formerly, a woman of good education, she was a ready talker and
P9ssessed the faculty of expressing her thoughts clearly and to the point.
Short periods of confusion were also reported in which she did not seem to
know What she was about. Memory, too, was rapidly becoming impaired,
and with all of it there was some depression and self-accusation. She fre-
quently remarked after the death of her son-in-law, “I did not do enough for
him. . He might have lived had I given him better care,” etc. She complained
of noises in the head which were described as “like a great rush of water”
and was frequently agitated over trifles. During the three days prior to being
Sent away visual and auditory hallucinations developed along with apprehen-
sive delusions based upon them. She would hide beneath the bed clothing;
cry out in terror, that “they” would put her to “the living death,” burn her
up, etc. She also spoke of hearing “voices from a throng of people,” of
seeing frightful animals on the bed and walls of the room, and begged not to
be left alone. During this excited period she was disoriented for time and
place, but recognized the members of her family.
August 7, 1911, she was sent to Dr. Ring's Sanatorium, Arlington, where
she arrived in a condition of stupor. An hour later she was aroused with
difficulty, did not know how long she had been there or where she was. When
questioned she replied only with a repetition of the question. During the
night she became more lucid, but was still disoriented; kept her head beneath
the bed clothing, was apprehensive and extremely noisy. She was also ac-
tively hallucinated, in the manner as described above. In consequence of her
disturbed condition she was removed to the Arlington Health Resort. On
arrival at that institution she was still hallucinated and appeared suspicious of
her surroundings. She did not, sleep during the first night, although she was
fairly quiet. The following day she had three epileptiform seizures which the
physician at that institution was inclined to consider of an hysterical nature.
No paralytic phenomena ensued. During the next day alternating periods
of confuson and periods of a fair degree of mental clearness are reported,
but at night she was very restless and talked a great deal in an incoherent
IT1a11116.1".
August Io, IQII. Increased apprehension, especially intensified when
left alone; active auditory hallucinations which seemed to form the basis
of delusions that men were coming to shoot her. She was very noisy and
exhibited considerable motor reproduction.
Gradually, in about three weeks, the apprehension and hallucinations
diminished, finally disappearing. She developed considerable insight, slept
well, enjoyed the visits of relatives, was out of doors most of the day and
looked forward to returning home a well person. This improvement,
however, was of short duration—less than a week.
One morning she seemed slightly depressed and refused food. During
the day she gave evidence of hallucinations, saying that she heard two
men in the field talking of killing her, adding spiritedly that she would not
be “shot down like a dog.” The old fears and apprehensions returned, but
she was not as noisy as formerly. She would hide or remain perfectly quiet,
and frequently begged to be protected from the torture that was coming
to her. She distrusted everyone, including her family, and developed
certain ideas of negation, as for example, she had “no husband,” “no
daughter,” “no nothing,” etc. She not only refused to recognize her
husband and daughter when they visited her, but handled them roughly
when they made advances. When they were about to leave her she al-
ways wished them to stay longer, even though a few moments before she
had said they were nothing to her.
This condition, our informant, Dr. A. H. Ring, states, persisted until
the patient left Arlington Health Resort, with addition of increased de-
pression, agitation, refusal of food and some retardation.
When admitted to Westborough State Hospital she was in rather poorly
nourished physical condition, and appeared considerably older than her
2I3
stated age (57), gait rather unsteady, but no indication of paralyses of
lower extremities. The heart’s action was rapid, but regular; no murmurs;
prominent and firm temporal and radial arteries; blood pressure (Tycos
instrument) I45. Respiratory sounds not pathological; urinalysis revealed
a diffused nephritis; other abdominal viscera negative. There was a peri-
neorraphy scar, the uterus small and fixed by adhesions. The skin was
sallow, presenting numerous moles, scars on the head, and right arm, and
the right ear badly mutilated as the result of the old injury.
The pupils reacted promptly to light, she did not coöperate in accom-
modation tests. Hearing in right ear greatly impaired, almost nil; ap-
rently good in left. Integrity or extent of impairment of Smell, taste and
tactile sensibility could not be definitely determined for lack of coöperation,
but she reacted rather promptly to painful stimuli. There was a rather
general coarse tremor, particularly marked in the tongue and fingers. Elbow
and wrist reflexes elicited, right K.J. plus, could not elicit left. No clonus;
no Babinski; no cranial nerve palsies or any other paralyses; some swaying
to Romberg.
The patient was very restless and markedly apprehensive. She did not
seem to understand many of the questions asked her, repeating them over
and over as though to grasp their meaning, or in a parrot-like manner.
Occasionally she gave a prompt and pertinent reply to a question, but
usually she employed indiscriminately the following phrases : “Sometimes,
I do, sometime I don’t,” “I don’t know,” or “that depends.” At one time
in the course of the interview she said, with an air of great significance,
“I comprehend lots of things I don’t pretend to know.” There was little
play of the emotions in her facial expression, except that of terror, and
on the whole she imparted the impression of considerable mental dulling.
Orientation was very imperfect. Although at the time of the interview
she had been but a few hours in the hospital she could not tell how long
here, where she had come from, the day of the week or month. She could
not give the commonest historical or geographical facts, nor tell how
many children she had. Retention was also very poor. She recognized
objects shown her and had no difficulty in imitating simple movements.
She was entirely without insight into her own condition.
For the two weeks following admission she slept poorly, ate but little
and cried much of the time. There were periods when she was very noisy,
during which she frequently left the bed to wander aimlessly about the
ward. The apparent difficulty in comprehending what was said to her still
persisted. She always repeated the questions and seldom added a per-
tinent reply. Spontaneous speech, however, was frequent, although for the
most part incoherent and in which there was frequent mention of Arling-
ton and of persons using her mind. She not only acted in a confused
manner, but once or twice nodded assent to the question, “Are you con
fused?” Although frequently confused she had not up to this time soiled
the bed or her person with feces or urine.*
In the early part of February, about six weeks after admission, she was
worse. Although kept in bed she was constantly restless, disarranging
the bed clothing, or moving her limbs about in aimless manner. She would
take but little food and strenuously resisted tube feeding. She was also
very resistive to all attempts to do anything with her, the basis of which
seemed a fear of all about her. She was even suspicious of the food. She
no longer made any attempt to answer questions or to comply with requests,
and frequently appeared confused. The content of spontaneous speech
was becoming more and more jargonic in character. A Nogouchi test for
syphilis was negative.
February 20, 1911, she was noticeably weaker. The heart's action was
rapid and irregular and examination of the chest revealed a pleuritis and
a developing right lobar pneumonia. She appeared very confused, babbled
almost constantly in an unintelligible jargon, and was very restless. The
only time, during a period of several days when she said anything which
was intelligible was when the clergyman visited her, she said to him “Get
* This was probably due to the excellent care of a very efficient nurse.
2I4.
out.” During the next three days the pneumonic process extended, and
now for the first time in hospital she passed urine and feces involuntarily,
The stools were diarrhoeic and there was almost constant drib-
bling of urine. There was swelling and redness of the knee joints and
beginning decubitus. The tongue was dry and covered with sordes and
she lay abed with mouth wide open, breathing laboredly.
February 24, 1911, death with symptoms of lobar pneumonia and cystitis.
Autopsy I4 hours, post mortem.
Anatomical Diagnosis.-Congestion of dura, hernia of Pacchionian gran-
ulations through dura, congestion, edema and regional proliferative
leptomeningitis chronica, diffuse atrophy of cerebral gyri, small patch of
atheroma in basilar artery, otherwise no macroscopic evidence of cerebral
arteriosclerosis; brown atrophy of heart, atheromatous degeneration
of endothelium of ascending aorta; acute exudative pleuritis, right lobar
pneumonia; hepatic congestion; chronic interstitial nephritis; gastritis,
acute enteritis; diffused nephritis, acute cystitis.
The brain weighed II27g., left cerebral hemisphere 497g., right hemi-
sphere 482g., cerebellum, pons and medulla I56g. The skull capacity as
estimated by the method of Rosanoff and Wisemann was 1270cc. The first
temporal, transverse temporal and supramarginal gyri of the right side
were smaller than the corresponding gyri of the left side. The rather
diffused atrophy of the cerebrum is slightly more marked on the right side.
The pial thickening and opacity is confined almost exclusively to the frontal
and upper two thirds of the parietal convexity. On section of brain no
gross focal lesions were found anywhere.
The spinal pia exhibited many small osteomata distributed chiefly in the
ventral portion of the thoracic area. The cord was of delicate proportions,
slightly congested, otherwise no gross lesions.
Histological Description.—The microscopical examination of the trunk
Organs is confirmatory of the anatomical diagnosis of the protocal, a detailed
description of which does not seem necessary. The histological alterations
of the brain we limit to what seem to us the most important features.
The cortical histological alterations are essentially those which charac-
terize a severe form of senile dementia, ganglion cell atrophies—in some
instances with superimposed acute changes—rich lipoid deposits in gan-
glion and glia cells, fine-fibered glia proliferations and cellular gliosis,
progressive-regressive changes in the vascular apparatus, so-called senile
plaques, and the like. In addition to these changes, particularly in left oc-
cipital convexity, are certain small areas suggestive of the areas found in
senile cortical devastation. The parts so affected are frequently of irregular
outline and commonly found at the bottom of sulci, although also seen in
the lateral and summit portions of gyri. These areas are not always coextant
with the triangular or wedge-shaped areas of cortical vascularization. but
always within and surrounding them are large glia cells. (Fig. 3) There
is not, however, any special fibrillary gliosis. Indeed, by the special glia
methods glia fibres are scant within these foci, the whole picture by prac-
tically all methods employed imparts the impression of a comparatively
recent process. The large pale cells seen in the devastated area (Fig. 3)
are glia cells.
In contradistinction to the comparative absence of macroscopic evi-
dence of cerebral arteriosclerosis in the larger vessels of the brain, the
microscopic examination reveals alterations in the smaller vessels of the
cortex and marrow, which are usually interpreted as arteriosclerotic changes,
such as proliferative changes in endothelium, splitting of the elastica, regres-
sive alterations of proliferated elements, a few instances of hyaline alteration
of the vessel wall, the arteriofibrosis of Friedman” which Simchowicz” and
one of us", separately, have illustrated in recent publications, vessel bud-
ding and so-called packet (Pakete) formations. The calcareous degeneration
of small vessels which Lafora” and Jansen” report as present in their cases
we did not find in this case.
2I5
The Alzheimer degeneration of intracellular neurofibrils (basket-like
ganglion cells in neurofibrils preparations) was not exhibited by a single
ganglion cell. Numerous areas of the cortex, basal ganglia, pons, me-
dulla, cerebellum and spinal cord were examined, more than 300 sections
prepared after the Bielschowsky, Levadiiti silver impregnation for trepi-
noma pallidum” and the Mann methods being employed. In this respect,
then, the case is like Alzheimer's second reported case", but there the likeness
ceases, in so far as the chief characteristics of neurofibril preparations of
this group of cases (plaques and basket cells) are concerned, but like all
other cases in the main histopathological alterations.
Senile plaques though present were neither large nor numerous in any
of the regions examined, not even in the prefrontal areas and hippocampal
gyri (Fig. 1) where generally these structures are the most numerous
and the largest, although in the right hippocampal gyrus, TI right, par-
ticularly in the portion of the latter forming a part of Campbell's audito-
sensory area”, they were more frequently encountered. Next to these
areas, the prefrontal regions of both sides and the right supramarginal
furnished the greater number. No plaques were found in the central
gyri, basal ganglia, pons, medulla, spinal cord and cerebellum. In the cere:
bellum, however, particularly in the sections prepared after the Levaditi
method, many amyloid bodies with fibrillary proliferations about the periph-
ery were shown. A similiar condition was also reported for the first
Westborough case of Alzheimer's disease".f
Although one of us has elsewhere shown" that the distribution of plaques
is generally diffuse in character, with accentuation where general histo-
logical alterations are greatest, it is not clear to our minds why the cere-
bellum and spinal cord should exhibit a comparative immunity. We have
instances on record at Westborough of plaques in medulla, but none in
the cord, even in those cases which showed them in the medulla. A feature
of the plaques in this case to which we would call attention is the
absence of the large centrally located nuclear-like body. Instead there is a
collection of smaller homogeneous masses, imbedded, as it were, in a
matrix of rather thick fibrils, some straight, others curled, the whole sug-
gesting a conglomerate. (Fig. 2.) The exceptions are the very small
plaques which Fischer” designates as Morgensternchen. Indeed, the larger
plaques not infrequently seemed to have resulted from a number of these
little star-like structures arising simultaneously within a small areua.
All the plaques encountered in this case we consider as young varieties,
in so far as one is justified in determining this from the character of the
glial reactions in their vicinity. Phe fibril components of these plaques we
judge to be chiefly neurofibril proliferations. In glia preparation we were
unable to demonstrate glia fibrils within the plaques, but of course we
recognize that that in itself would not exclude their existence in Weigert
ºtions. The Mann sections were also negative for a fibrillary
g|1OS1S.
The rather peculiar reaction in Herxheimer's scarlet stained sections—
fine red stippling of the entire plaque—which Alzheimer described in his
second case and which was also found in the first Westborough case we
did not demonstrate in the present case.
The above are the essential clinical and anatomical data of
this case.
*We have found this method useful for the demonstration of plaques and can con-
firm A. Hauptmann’s statement, Zeitschr. f. d. ges. Neurol. w. Psych., Bd. 9, S. 239, 1912,
that more plaques are exhibited by this method than by the Bielschowsky method, and
is to be recommended where plaques are scantily shown by other methods. For finer
plaque details, however, we prefer , the Bielschowsky method and Mann's eosin-
methyleneblue staining as recommended by Alzheimer.
iTt may be well in this connection to call attention to recently published views of
Alzheimer and of Bielschowsky concerning amyloid bodies. These observers point out
the similarity of chemical make-up and the probability of a common origin from , de-
generating nervous elements. At any rate, one seems justified in deducing from their
statement that they argue a similarity if not a like origin for plaques and amyloid
bodies, structures so common in brains undergoing senile involution.
2I6
Now how shall we group the case here reported and the other
reported cases of so-called Alzheimer’s disease; is all the data
sufficient to warrant a new clinical group, or is it better to in-
terpret them as representative of a phase of senile dementia, a
precocious senile dementia, or, if you will, an atypical senile de-
mentia? At all events, if we take the ground that these cases fit
best into the Senile dementia group, it will be conceded that they
are not of the sort commonly designated as “simple senile de-
mentia,” for their clinical histories and anatomical findings best
comport with the severer forms of senile dementia. If, then, these
are cases of atypical Senile dementia, the question could fittingly
arise why a special clinical designation—Alzheimer's disease—since
after all, they are but part of a general disorder. Still the profes-
Sion must remain indebted to Alzheimer for having first called
attention to this type of cases. He himself does not claim a distinct
clinical entity for the group, for in the discussion of his second
reported case" he states as his conviction that, since there were
many points of contact, to say nothing of similarities, between this
group and Senile dementia, there was no good ground for supposing
a special pathognomonic process; that the cases were representa-
itve of a senile psychosis—a typical senile dementia—a view which
is shared by Bielschowsky,” Lafora,” Jansens" and the writers.
Barrett,” in the report of a group of cases among which was
included a case of the type under consideration, although not re-
ported as such at the time, considered that plaques in combination
with basket-like degenerations of ganglion cells, together with cer-
tain focal atrophies of the brain which his cases presented, offered
“explanations of a special clinical group of Senile psychoses.”
So that here also we have a case reckoned with the general mental
disorders of senium.
Schnitzler's case,” at first sight, is disconcerting, for it is
difficult to conceive of senile dementia in a person of thirty-two.
Nevertheless, Schnitzler groups his case with the type of which
Spielmeyer writes as, “cases of senile dementia which differ from
the usual type in that a marked dementia rapidly ensues, together
with focal symptoms of asymbolic and aphasic character.” He
also shows an inclination to flirt with the rather fascinating idea
of an origin from disordered internal secretions (ductless glands),
since his case and one of the cases reported by Perusini" exhibited
certain myxedematous symptoms.
It is seen that all observers who have reported cases of
Alzheimer’s disease consider them as belonging to the senile
group, although in most instances of precocious onset. We then,
it appears, have to deal with an atypical form of senile dementia.
But what are we to understand by senility in an anatomical or
217
psychiatric sense?” Anatomically we are as yet unable to draw
a line with any degree of precision between the brains of some so-
called normal elderly persons and certain senile dements. Still,
while definite anatomical criteria may be lacking, in so far as
concerns senile dementia, on the psychical side the lines are per-
haps better demarcated. It is recognized that general dulling,
memory weakening, disturbances of retention, impairment of judg-
ment, lessened initiative, inability to concentrate the attention on
matters formerly of interest and a weakening of the normal af-
fectivity are hall marks, so to speak, of senile mental disorder in
general. The lessened interest and the more or less profound
disturbances of retention which accompany the dementia of senile
insanities serve in a great measure to differentiate them from the
inherited or other defect—psychoses. Nowadays one would hesi-
tate to say that “a man is as old as his arteries,” for the mental
disorders of senium and arteriosclerosis are well defined, although
often found in combination. One also hesitates, in spite of the
intensive manner in which our knowledge concerning plaques has
been recently cultivated, to reduce senile dementia to terms of
plaques. The case of Schnitzler, admitting that as an example of
an atypical senile psychosis, the two cases of circumscribed senile
atrophies of Alzheimer," the case here reported with but few
plaques, the recently reported group of Westborough cases which
coursed clinically as senile dementia yet anatomically presented no
plaques,' all give pause.
The case which forms the subject of this paper is in our
opinion an example of the group now designated as Alzheimer’s
disease, although varying somewhat from the first Westborough
case and other reported cases. The antecedent ill health and
mental stress, the mode of onset with apprehension and depres-
sion, periods of mental confusion and active hallucinations, fol-
lowed by a short period of remission, were such as to suggest
several possibilities. Among the possible psychoses considered
were the infective-exhaustive group, manic-depressive insanity,
Kraepelin's melancholia—now in disrepute in certain high quar-
ters—and arteriosclerotic insanity. Although general paresis or
cerebral lues was not seriously considered, a Nogouchi test of
the blood was made. This proved negative. Soon, however, the
marked disturbance of memory and retention, the aphasic disorders
of a sensory character, the periods of confusion, restlessness and
motor reproductivity, together with the earlier epileptiform con-
vulsions without motor residuals, aroused the suspicion of a pos-
sible case of Alzheimer's disease, which we believe the subsequent
course and anatomical findings as a whole justify us in maintaining.
*Whether, senium is a normal or pathological process has been the subject of much
discussion, which leaves the problem far from solution.
218
REFERENCES.
I. Fuller, S. C.: Alzheimer's Disease (Senium Praecox): The Report
of a Case and Review of all Published Cases. Jour. Nerv. & Ment.
Disease, Vol. XXXIX. 1912. And Ein Fall der Alzheimerschen
Krankheit Zeitsche. f. d. g. Neurol. u. Psych. Bd. II, s. 158, 1912.
2. Alzheimer, A. : Ueber eine eigenartige Erkrankung der Hirnrinde.
Allg. Zeitschr, f. Psych, Bā. 64, S. I.46. Igo7.
3. Perusini, G. : Ueber klinisch und histologisch eigenartige psychische
Erkrankungen des späteren Lebensalters. Nissls u. Alzheimers
Arbeiten, Bd. 3, S. 297. 1909.
4. Alzheimer, A. : Ueber eigenartige Krankheitsfälle des späteren Alters.
Zeitschr. f. d. g. Neurol. u. Psych., Bd. 4, S. 356. Igi I.
5. Friedmann.; Die Altersveränderungen und ihre Behandlung. Berlin
u. Wien, 1902.
6. Simchowicz, T. : Histologische Studien über die senile Demenz.
Nissls u. Alzheimers Arbeiten, Bd. 4, S. 267, 1911,
7. Fuller, S. C. : A study of the Miliary Plaques Found in Brains of the
Aged. AM. Jour. INSANITY, Vol. LXVIII, p. 147. IQII.
8. Lafora, G. R. : Beitrag zur Kenntnis der Alzheimerschen Krankheit
oder Präsenilen Demenz mit Herdsymptomen. Zeitschr. f. d. g.
Neurol, u. Psych., Bol. 6, S. 15. I91.I.
9. Jansens, G. : Ein Fall der Alzheimerschen Krankheit. Casuistischer
Beitrag. Psych. en Neurol. Bladen. No. 4 en 5. IQII.
Io. Campbell, A. W. : Histological Studies on the Localization of Cerebral
Function. London, Cambridge University Press. I905.
II. Fischer, O. : Die presbyophrene Demenz, deren anatomische Grundlage
und klinische Abgrenzung. Zeitschr. f. d. g. Neurol. u. Psych., Bd.
3, S. 371. I91O.
I2. Bielschowsky, M.: Zur Kenntnis der Alzheimerschen Krankheit (prä-
senilen Demenz mit Herdsymptomen). Jour. f. Psychol. u. Neurol.,
Bd. 18, Ergänzungsheft I, S. 274. IQII.
13. Barret, A. M.: Degenerations of Intracellular Neurofibrils with
Miliary Gliosos in Psychoses of the Senile Period. AM. Jour.
INSANITY, Vol, LXVII, p. 503. I9II.
I4. Schnitzler, J. G. : Zur Abgrenzung der sog. Alzheimerschen Krankheit.
Zeitschr. f. d. g. Neurol. u. Psych., Bd. 7, S. 34, 1911.
EXPLANATION OF PLATES.
FIG. I.-Hippocampal gyrus rt. Levaditi method for Trepenoma pallidum
as recommended by Hauptmann for plaques. This photograph
shows as rich a field as found anywhere in the numerous sections
examined. Bausch & Lomb 2-3 achromat. Obj, Zeiss projection
oc. No. 2, bellows extension 84 cm.
Fig. 2.-TI re. Bielschowsky silver impregnation. Large plaque suggestive
of the conglomerate described in text, and several smaller plaques,
latter not in good focus. Zeiss 2 mm. apochromat. Obj., projec-
tion oc. No. 2, bellows extension 90 cm.
Fig. 3–Left occipital convexity. Area not unlike, senile cortical devasta-
tion. Toluidin blue, after Nissl. Zeiss AA. achromat. obj., no
ocular, bellows extension I m. 65 cm.
WEST BOROUGH STATE HOSPITAL PAPERS (Series I) PLATE XXXIX.
º --
- ſ?
-

WTST BOROUGH STATE HOSPITAL PAPERS (Series I)
PLATE XL.
Fig. 2.

WEST BOROUGH STATE HOSPITAL PAPERS (Series I)
PLATE XLI.
---
----
----*** · · · · · · ·
|-
- .|-|-
ſº， º ~
-- .|----
|-* ..." --
-
----
|-'
-
- - - - - -
> *
FIG, 3.




XV
A CASE OF HUNTINGDON'S CHOREA
BY SoLoMon C. FULLER, M.D., AND JoHN F. LovELL, M.D.
The more recent papers dealing with Huntingdon's chorea,
indicate that, quite regularly, one may find degenerative lesions,
particularly microscopical alterations, in the cerebral cortex and
other portions of the brain, especially in the basal ganglia—caudate
and lenticular nuclei, and subthalamic region. While gross an-
atomical alterations, such as diffuse and regional atrophies, are
also reported, these have been assigned less weight, for the reason
perhaps, that diffuse and regional atrophies are an accompaniment
of many organic brain conditions and mental disorders. The basal
ganglia changes have recently assumed considerable significance
in the pathological anatomy of chronic progressive chorea.
Indeed, by some, these changes are already interpreted as the
anatomical substrate of the choreic movements which are so promi-
nent among the characteristic symtoms of the disease. Not only
for chorea major have the basal ganglia changes been made
responsible, or at least looked upon with suspicion as the anatomi-
cal factor, in the production of choreic movements, but they have
also been made to serve the same purpose for chorea minor.
We would not have it understood, however, that on the anatomi-
cal side Huntingdon's chorea has been definitely reduced to
microscopical alterations focalized in the basal ganglia and sub-
thalamic region, for practically all observers mention the diffuse
distribution of degenerative lesions throughout the brain, even
though these lesions vary in their intensity in the different portions
of this organ. Nevertheless, Jelgersma maintains that, particu-
larly in those cases of Huntingdon's chorea with late onset, the
degenerative process begins in the basal ganglia, and in occasional
cases is confined solely to this region.
Several observers (Keraval, Raviart,” Clarke, Good,” Rusk"),
in their descriptions of the cerebral cortex of subjects dying of
Huntingdon's chorea, have called attention to a certain strata-
graphic distribution of the severer histopathological lesions, cor-
responding in location to the area designated by Brodmann'
as lamina IIIa.
Other writers (Suckling,” Moebius") have argued an anlage—
developmental disturbances, more specifically an arrested differen-
tiation of the cortical layers, whereby a certain infantile or em-
bryonic lamination persists. This arrested cortical differentiation
()
22O
affects particularly the types of cortex which Brodmann has
classed as heterotypischen Formationen.
For the etiology of Huntingdon's chorea, Kolpin” makes
responsible a combination of all of the factors which we have
mentioned. Thus in the conclusion of Koplin's paper one may
read the following:
“Die Huntingtonsche Chorea ist der Ausdruk einer diffusen Erkrank-
ung des Zentralnervensystems, insbesondere des Grosshirns. Sie en-
twickelt sich auf einer degenerativen Grundlage, d. h. Sie hat zur Vor-
aussetzung ein minderwertiges Gehirn. Diese Minderwertigkeit kann sich
dokumentieren durch strukturelle Anomalien, die in Form einer Art von
Entwicklungshem mung (Stehenbleiben einzelner Rindenterritorien auf einem
infantilen resp. juvenilen Schichtungstypus, Vorkommen cellularer Jugend-
formen) nachzuweisen sind. Der Krankheitsprozess selbst ist charakter-
isiert durch das Zugrundegehen nervéser Bestandteille sowohl in der Hirn-
rinde wie in den subcorticalen Ganglien, das bisweilen zu recht beträcht-
licher Atrophie des Gehirns führen kann. Neben den atrophischen Vor-
gangen finden sich in manchen Fällen reparatorischen Wucherungen von
seiten der Glia. Die vorderen Partien des Gehirns pflegen starker wie die
hinteren, die oberen Rindenschichten mehr wie die unteren betroffen zu
Sein.”
While admitting that degenerative lesions may be found with
great regularity in the cortex of persons dying of Huntingdon's
chorea, Alzheimer" thinks it debatable that along with these corti-
cal changes developmental disturbances can also be established,
nor does he believe that the cortical lesions play any great rôle in
the production of the characteristic choreic movements. He is of
the opinion that the anatomical substrate, of choreic movements
in general, is to be found in the alterations seen in the basal
ganglia and subthalamic region. Two cases of Huntingdon's
chorea and two each of Septic and rheumatic chorea studied by
Alzheimer exhibited the severest lesions in the regions mentioned.
The character of these basal ganglia and subthalamic region
changes will be considered later in the course of this paper.
The case here reported, among other things, seems to us
of interest for the following reasons: first the evident familial
character of his affection, for he is the fourteenth known member
of the family to suffer from chorea within five generations;
second, most of the known cases in this family have developed
chorea late in life; third, certain mental Symptoms and histopatho-
logical alterations of the brain, particularly the latter, must be
classed as the result of senile involution, so that one is at a loss
how much of the final mental picture to attribute to a coincident
senium and how much to Huntingdon's chorea. Moreover, the
question has arisen in our minds as to whether or not we were
dealing with an actual case of Huntingdon's chorea or a senile
chorea which, as commonly happens with arteriosclerosis, has
tended to occur in the family of this man. A further question has
22I
also arisen. Assuming an anlage as requisite for the development
of Huntingdon's chorea, and that the weak spot, so to speak, is
not the type of cerebral cortex mentioned above, but the basal
ganglia, can this anlage be made to do duty for Senile chorea and
the symptomatic choreas following septicaemia and rheumatism?
Our case presented histopathological alterations in the basal
ganglia and subthalamaic region comparable to those described
by Alzheimer" for Huntingdon's chorea, though less stormy in
character. The cerebral cortical changes were so like those
described by one of us (elsewhere in this volume”) for certain
cases of senile dementia (miliary plaques and Alzheimer degenera-
tion of ganglion cells in hippocampal gyri and cornu Ammonis)
that it seems futile to attempt to establish any stratigraphic
distribution of the lesions with reference to Huntingdon's chorea.
The history of the case is as follows:
No. 9959, a man of eighty years, presenting a rather pro-
nounced chorea and considerable mental enfeeblement, was ad-
mitted to Westborough State Hospital, Jan. 28, 1912.
Family History. (Furnished by wife and son). In the three
generations preceding, similar cases of chorea have occurred in
the family, but of these there are only two of which the informants
have any detailed knowledge, Lydia S., the patient’s mother and
Jesse an uncle. Lydia S. developed the disease between the age
of forty and fifty, later dying after a psychosis had supervened.
Jesse, the brother of Lydia also developed the disease at middle
life and he had a son who died from chorea (age of development
not known). Lydia S. was the mother of thirteen children. The
first two children, Harriet and Orra, and Walter (patient) the
twelfth child, suffered from chorea. Harriet developed the disease
in middle life and had pronounced mental symptoms. She was
the mother of four children and one of these, a daughter, developed
a similar condition at the age of forty-five, dying fifteen years
later. Orra is reported to have been a brilliant woman. She did
not develop the disease until late in life, between sixty and seventy,
but it is said that her condition was never as severe as that of
her sister Harriet, or her brother Walter (patient). Orra was the
mother of two sons, neither developed the disease and both died
without issue. Walter (patient) is the father of three children.
One of his children died in infancy (scarlet fever), the other two,
a daughter of fifty-three and a son of forty-five, are well and free
from signs of chorea. The daughter of Walter had two children,
one died of tuberculosis at the age of twenty, the other now in
young adult life is free from the disease. The son of Walter has
one child, a son, who is also free from chorea.
Thus, including Lydia and Jesse, seven cases of chorea are
222
known in three generations. Seven other cases are known to have
occurred in the two generations preceding Lydia and Jesse,
but of these data is inadequate and not trustworthy as to exact
relationship. It is more of the nature of tradition that seven
members had suffered from the disease.
Previous History. When the patient was five years of age
he met with an accident, falling from a rocky embankment into
a body of water and was nearly drowned. He was resuscitated
Only after several hours' work over him. Aside from this, no
Serious illness or accident is reported until he was fifty when he
again met with an accident—he cut his knee severely with an axe.
About twenty years ago, when he was sixty, he began to have
choreic movements. Two years later he met with still another
accident, a log rolled over him, crushing one of his hips. After
this the choreic movements became more pronounced and have
steadily grown worse. His family did not notice any mental
change until five years ago—speech disturbance, difficulty in
making himself understood, and irritability as a result. During
the last two years he has been hallucinated, spoke of a twin brother
who was constantly around talking to him and wearing his clothes,
etc. During the ten days prior to admission he had been very
restless, particularly at night; had talked a great deal in a rambling,
disconnected manner; and fabricated experiences of adventures.
He has never been a drinking man. Most of his life has been
spent as a farmer, and he has borne a reputation for thrift and
integrity. Education was limited to a year in high school. Since
the development of his chorea, he has shown a fondness for read-
ing and has spent much of the time reading, or at least with a book
in his hand as though reading.
Here. On admission pronounced choreic movements of the
extremities, torso, head, tongue and pharyngeal muscles, the
latter rendering speech extremely difficult, not only to emit but
also to understand. General nutrition is fair; heart’s action is
irregular and tumultuous; systolic murmur heard at apex; pulse
rapid and soft; varicose veins of the legs. The tonsils are enlarged,
the buccal mucosa dry, and there are sordes on the lips, teeth
and gums; albumin and casts in urine; no pathological lesions of
abdominal viscera detected. A large reducible inguinal hernia
presents on right side and a smaller hernia of the same character
on the left side. Sebaceous cysts over left flank and over both
scapulae; skin sallow and scrawny; recent bruises.
The pupils measure approx. 3mm. in diam., and react to
light and accommodation. There is a catarrhal conjunctivitis.
Patient does not cooperate further in the sensory examinations,
but hearing is somewhat impaired. There are no paralyses;
223
Some tremor is noted in the intervals between the choreic move-
ments; no contractures. The gait is frequently interfered with
by the choreic movements; it is erratic, seldom reaching the
intended goal, otherwise there is nothing save a degree of trepi-
dancy. -
Mentally, he was very irritable, pugnacious and resistive. It
is necessary to employ considerable tact in order to accomplish
anything with him. When told that he was in a hospital for the
insane, he remarked, “I am damned glad of it.” He had said
previously that he knew he was in hospital, but did not know
what kind. Once during the interview he said his son was the
foreman of this building, this after he had been told its nature.
He denied hallucinations and insisted that he was perfectly well
mentally and physically. When it was suggested that it was
difficult for him to control the movements of his arms and legs,
he was very indignant, insisting that he had perfect control over
them.
His memory, he said, was fine, but on the day after his
admission he could not tell how long here, give his age correctly,
the date of his marriage, the number of his children, or even his
own first name. He also romanced freely when asked to give an
account of what he had done the two days previous. There are
ill defined ideas of persecution, he thinks his son has not dealt
properly with him.
Excepting occasional periods of excitement and restlessness
with which there was some mental confusion, the above condition
remained much the same until March 14. His right arm became
infected through an abrasion produced by banging it in one of
the choreic movements. The infection, a staphylococcus, grew
worse rapidly; he was confused most of the time and very weak,
dying six days later, March 19, after a hospital residence of one
month and nineteen days.
Autopsy three hours post mortem.
Anatomical Diagnosis. Chronic external pachymeningitis,
chronic proliferative leptomeningitis, cerebral atrophy—particularly
of corpus striatum—advanced cerebral arteriosclerosis; chronic
endocarditis; moderate pulmonary hypostasis (rt.); passive con-
gestion of liver; Splenic congestion; congestion of gastric mucosa,
calcification of mesenteric lymph glands; chronic interstitial
nephritis; infected incised wounds of right hand and arm.
Abstract of Autopsy Protocol. The calvarium is of increased
density and diploé are scant. The dura is abnormally adherent—
it is necessary to cut through the membrane in order to remove
the skull cap. The pia is congested, edematous and opaque, the
opacity rather generally distributed over the convex and mesial
224
surfaces of the cerebrum. There is also some clouding of the
membrane Over the basal portion of the frontal lobes and of the
portion of the membrane distributed to the anterior and posterior
perforated Spaces. The large vessels of the base and some of the
Smaller twigs distributed to the convex and mesial surfaces of
the cerebrum are markedly sclerotic and atheromatous. The
whole brain is congested. The cerebral gyri are rather generally
atrophied; the Sulci tend to gape, particularly in the frontal lobes.
The cerebral hemispheres are symmetrical, and the surface topog-
raphy of the brain shows no variations which may be interpreted
as abnormal. Despite the apparent atrophy, the general consis-
tence of the brain may be described as soft, certainly not as firm
as many brains which show a like degree of atrophy. The hypo-
physis and its fossa offer no gross lesions. The brain with pia
attached, and before sectioning, weighs IOO6.4 grams.
The cord is congested, its pia slightly clouded, exhibiting a
few small osteomata. Other than this the cord offers no macros-
copic alterations. After removal of small blocks of brain and
segments of the cord for fixation in alcohol, Flemming's solution
and Weigert’s glia mordant, the remaining portions were fixed
en masse in IO per cent formalin.
Section of Brain after Formalin Fixation. Coronal sections
were taken at intervals of one centimetre through the cerebrum,
pons and cerebellum. The most striking features revealed are,
atrophy and gaping sulci, noted in the fresh brain, a rather marked
atrophy of the basal ganglia, particularly of the caudate nucleus
and the gray substance of the subthalamic region. (Figs. I, 2, 3
and 4.) These photographs are taken to represent the exact
size of the brain. The slight loss in focus of Figs. 2 and 3,
however, have produced a slight enlargement in the perpendicular
and horizontal diameters, but this by measurement is less than
2 111111.
In Fig. 4, at a point indicated by an arrow, is shown a small
pear-shaped mass of gray matter, slightly superior to and mesial
to the tegmentum and isolated from the subthalamic gray matter,
inclosed save at its most inferior portion by white matter. Stream-
ing into this isolated gray mass are fine strands of white fibers.
Microscopically the area is crowded with rather large ganglion
cells, very much after the character of the ganglion cells found in
the nucleus of Luys’.
Microsopical Examination. In sections stained with toluidin
blue after alcohol fixation, one finds in the cerebral cortex (prefron-
tal area FI and F2, F3, left tranverse temporal gyri, left, paracentral
and antr. central of both sides, supr. parietal right and calcarine
type of cortex) extensive chronic nerve cell changes—rich lipoid
225
content, particularly of the cells of the outer laminae and the smaller
cells of the deeper layers, dark staining, tortuous dendrites and
many shadow forms of the small and medium size pyramidal cells,
many areas (usually round and indiscriminately distributed
through cortex, particularly in paracentral, anterior central,
hippocampal gyrus and cornu Ammonis) in which there are no
cellular contents. These areas are shown by other methods to
be the position of so-called senile plaques. Glia nuclei are increased
throughout the cortex, and this is particularly noticeable in the
molecular layer, where in some areas it is very marked. The
blood vessels, alike in pia and cortex, present progressive-regres-
sive changes and many very small vessels are shown in a state
of calcareous degeneration. In addition, many small haemorrhages
are encountered, usually in the outer laminae of the cortex, but
also in the other layers and in the white substance, generally
encircling a small vessel. There are numerous small, circular
clear spaces, having much the appearance of the post mortem air
cysts of B. aerogenes capsulatus, but these we are convinced are
simply residuals of small haemorrhages, for in some of them may
be seen the rests of erythrocytes. None of these cyst-like areas
or even the fresh haemorrhages show any reaction in their im-
mediate vicinity of the glia or nervous apparatus which can be
demonstrated in Nissl toluidin blue specimens, or with the IV, V,
VI procedures of Alzheimer, except recent haemorrhages in basal
ganglia around which are amoeboid glia cells. With Mann's stain,
acid fuchsin-light green stains and the Bielschowsky silver im-
pregnation numerous senile plaques are encountered in all areas
of the cortex examined, but most numerous in the hippocampal
gyrus and cornu Ammonis, and in the paracentral and
anterior central cortex. In the cornu Ammonis ganglion cells
showing the so-called basket form of degeneration are encountered.
When the basal ganglia are examined (caudate, lenticular,
Luys, thalamus and red nuclei) even more extensive degenerations
of the nervous apparatus are shown. We did not find a single
ganglion cell which could be described as anywhere near normal.
All of the ganglion cells remaining were greatly crowded with
lipoid granules, for the most part yellowish granules, but along
with these, in the Mann stained specimens, were numerous blue
granules. Intermingled with the fibers were many glia cells of
the type described by Alzheimer as amoeboid glia cells. Some
of these cells were very large, larger than some of the large
ganglion cells of these nuclei and were found where there was
evident recent alteration of fibres. Often in their vicinity were
bluish tinged masses of varying nuance and size. These
large cells, however, were not frequently encountered, the smaller
226
type of amoeboid glia cells predominating, and only very rarely
were they associated with the presence of so-called Fuhlkorperchen.
In the spinal cord, by none of the methods employed were
acute changes found, such as Alzheimer” has illustrated from a sec-
tion stained with Mann's solution. The changes here are evidently
chronic in character. Appreciable glia fiber proliferation is shown,
particularly in the lateral columns. In addition numerous amyloid
bodies and the haemorrhages described above are also seen.
The ganglion cells of the gray matter while many of them evidence
chronic nerve cell changes, are better preserved than ganglion cells
elsewhere encountered.
Resume. A man of eighty, the fourteenth known member of his
family within five generations to suffer from a chronic progressive
chorea, developed the disease at the age of sixty, but is said to
have preserved his usual mentality for fifteen years after its
Onset, when he began to show mental symptoms resembling the
mental disorder of senium. Anatomically, in the cortex, the
lesions were like those which have been described for severe
Senile dementia, and in addition to these, chronic and acute
degenerations in the basal ganglia, the latter characterized by the
presence of many so-called amoeboid glia cells and split products of
pathological metabolism of nervous elements, the so-called Fuhl-
korperchen. The histopathological lesions on the whole are quite
comparable to those described by Alzheimer for Huntingdon's
chorea, though less stormy in character.
REFERENCES.
Jelgersma : 8o Versammlung Deutscher Naturforscher u. Aerzte, Cöln,
Sept. 20-26, 1908.
Keraval: Cited by Kölpin, 1. c. 10, 1908.
Raviart: Cited by Kölpin, 1. c.
Clarke: Cited by Kölpin, 1. c.
Good: A Review of Chronic Progressive Chorea (Huntington's), with
Report of a Case. Am. Jour. Insanity Vol. LVII, p. 21, 1900.
Rusk: A Case of Huntington's Chorea with Autopsy. Am. Jour. In-
sanity, Vol. LIX, p. 63, 1902.
Brodmann: Feinere Anatomie des Gehirns, Handbuch der Neurologie,
(Allgemeine Neurologie), Herausgeben von M. Lewandowsky, Bd. 1,
pp. 206-307. IQIO.
8. Suckling: Hereditary Chorea. British Med. Jour., 1889, p. Io99.
9. Moebius: Ueber Seelenstörung bei Chorea. Neurol. Beiträge H. 2, p. 123,
and Münchr. med. Wochenschr., 1892, p. 925. &
Io. Kölpin: Zur pathologischen Anatomie der Huntingtonschen' Chorea.
>\ Jour. f. Psychol. u. Neurol., Bol. I2, p. 57., 1908.
II: Alzheimer: Uber die anatomische Grundlage der Huntingstonsche
Chorea und der choreatischen Bewegungen überhaupt. Authors re-
view in Archiv f. Psych., Bd. 49, p. 326, 1912.
12. Fuller: A Study of the Miliary Plaques Found in Brains of the Aged.
This Volume (WESTBOROUGH STATE HospitaL PAPERs, SERIES I.), 1912.
I.
WESTBO ROUGH STATE HOSPITAL PAPERS (Series I) PLATE XLII.

WEST BOROUGH STATE HOSPITAL PAPERs (series I) PLATE XLIII.
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WEST BOROUGH state HospitaL PAPERs (series I) PLATE XLIV.

WEST BOROUGH STATE HOSPITAL PAPERS (Series I) PLATE XLV.