BY BEATRICE A. STEVENSON, M. D., and H. D. PURDUM, M. D., Assistant Physicians, Northern Michigan Asylum, Traverse City, Michigan.

This case has been selected, from a comparatively large number admitted to this institution, as one to satisfactorily demonstrate practically all of the cardinal features of this most interesting and obscure disease, Huntington's chorea.

A. W., female, was admitted to the Northern Michigan Asylum, January 15, 1903, and died May 26, 1908.

The abstract of the history is as follows: Father and mother were natives of England, were not related and were, respectively, 23 and 21 years of age at the time of the patient's birth. No nervous peculiarities were recorded in reference to the paternal side of the family.

The maternal records revealed the following: Maternal grandfather, two aunts, three uncles, ten cousins, mother and two sisters had, or now have, this disease. Two brothers have been sentenced for arson and theft and a son of the patient is now in a reformatory.

The patient was born in the State of Michigan, in 1860. The developmental period was uneventful. During her early adult life she enjoyed fair physical health, though she was considered to be of a nervous temperament and was subject to attacks of fainting, palpitation and vasomotor irritability. She married at the age of 24 and had seven children. Her married life was an unhappy one and was attended by hard work and mental stress.

The first choreiform movements were noted at the age of 36. These were soon followed by gradual progressive mental deterioration with heightened emotional feelings. Nine years after the first choreic movements were observed the patient became depressed, entertained fears of becoming insane, had delusions of persecution and grandeur, together with auditory and visual hallucinations. Later on she became irritable, quarrelsome and aggressive, and demonstrated complete loss of self-control by violent outbursts of passion.

On being admitted to the hospital, she was emaciated, weak and in a much neglected condition. Her lips and teeth were covered with sordes, tongue was coated and breath offensive. Temperature was 99.6; pulse, 110. Respirations could not be satisfactorily counted because of the more or less constant choreic spasms which involved the face, trunk and extremities. Patient was unable to stand, walk or sit in a chair without support on account of her generally weakened state and incessant spasmodic movements. A thorough physical examination of the internal organs failed to reveal any evidence of disease. Deep reflexes were mark

edly exaggerated; superficial, slightly so. Pupils were equal, circular, and reacted to light and accommodation. The special senses were active as far as could be determined. Urine contained a trace of albumin and a few hyalin and granular casts. Blood was light red in color and its coagulability lessened. Hemoglobin was 68 per cent; erythrocytes, 3,468,000; leucocytes, 4948. A differential count did not show any departure from the normal proportion of the various white cells.

One week after admission a mental status was made and the following recorded:

Patient is cared for in bed and requires a great deal of special attention on account of her untidy habits and destructive tendencies. Appetite is good, but sleep insufficient. She is incapable of caring for herself and has been noisy, irritable and restless. Movements are extensive, involving the entire body. The facial expression is constantly changing. The extremities jerk and the body is thrown from one side of the bed to the other. She picks at and destroys the bed clothing and makes a clucking noise with her lips and tongue. A sustained conversation is impossible. Her replies to questions are irrelevant and with great difficulty understood, as she cannot articulate distinctly. Occasionally she whispers to herself or screams as if hallucinated. Deterioration is marked, consciousness clouded and orientation imperfect.

Memory for both remote and recent events is poor, and chronological sequence markedly impaired.

Ideation is imperfect, patient being unable to associate properly. Some distractibility with flight of ideas and looseness of thought connection is noted.

Judgment is greatly affected, this being partially due to memory impairment and partially to delusional ideas. The delusions entertained are of an expansive and depressive nature, and are evidenced by her actions and fragmentary remarks. She has no insight into her condition.

The emotional state is one of more or less constant irritability. The affect is completely changed and patient is violent toward those who care for her. The finer sensibilities are blunted. Hunger, fatigue and sexual feelings are more or less in abeyance.

Will power is diminished, and impulsive and compulsive acts occur, patient having attempted suicide several times since being admitted. Occasionally she resents attention and becomes quite aggressive and violent.

The above physical condition and mental peculiarities remained more or less stationary except that the mind gradually deteriorated and the body became weaker. Suicidal tendencies and delusional ideas faded as the dementia progressed. It was difficult to prevent bed sores, as the friction produced by the constant muscular spasms wore away the skin. It became necessary to remove the three central incisors from the upper jaw, as the continuous forcible movements of the lower jaw had loosened them until they stood out between the lips. In the early part of April, 1908, patient contracted acute pulmonary tuberculosis and death occurred May 26, 1908. Autopsy, 15 hours after death.

Protocol: Body of a female of medium height and slight frame. Emaciation extreme. Post-mortem rigidity present and lividity over dependent portions of the trunk. Large decubitus chronicus over sacrum. Eyes directed forward. Pupils, 4 millimeters in diameter; circular and equal. Facial features symmetrical. Extremities are of equal size on the two sides.

Head Section: The tables of the calvarium are thickened at the expense of the diploe. The dura is diffusely thickened and firmly attached to the overlying skull cap, but not to the pia-arachnoid. Brain weighs 1050 grams with membranes. Arachnoidal and perivascular spaces are dilated by straw colored fluid. Blood vessels over the brain surface are engorged with a dark colored blood. Over the tips of the frontal lobes some slight extravasation is present. The pia is diffusely thickened, this being particularly noticeable along the course of the blood vessels. On removing the pia-arachnoid from the underlying convolutions, the cortical surface presents a dull appearance instead of a normal, smooth, glistening one. The upper portions of the Rolandic areas, superior convolutions of the parietal lobes and tips of the frontal lobes have lost their normal plumpness. Some of these gyri are quite narrow and a trifle retracted; others are not so badly affected. The surface appearance of the remaining portion of the brain shows no marked departure from the normal. The cut surface after a vertical section of the brain, presents a thin cortex, some medullary shrinkage, dilated ventricles and numerous little red weeping points, the sites of the cut, engorged blood vessels.

Macroscopic appearance of the cerebellum, pons, medulla and spinal cord is negative.

The gross changes found in the other organs of the body were not sufficiently interesting to justify a detailed description here.

Sections for microscopic study were taken from the brain, cord, lungs, heart, aorta, liver, spleen, kidneys, suprarenal glands, cervix and ovaries. The stains used for the tissues were Nissl's, Marchi's, Weigert-Pal's, Van Gieson's and eosin-hæmatoxylin.

The microscopic findings of the general tissues were as follows: The left lung showed an acute tuberculous process involving all three lobes. The right lung was negative except for a small pneumonic area situated in the lower portion of the upper lobe. The muscle cells of the heart were shrunken and the nuclei appeared to be quite numerous on account of the cells being small and the connective tissue proliferated. The coronary arteries were thickened; this thickening being more evident in the intima and adventitia. The specimen of the aorta showed a marked diffuse proliferation of the endothelial cells. The liver showed considerable hyperplasis of the connective tissue, also numerous fat droplets in its parenchyma cells. The specimen taken from the spleen revealed a definite chronic interstitial and perisplenitis. The trabecula were more numerous and larger than normal, and the splenic pulp diminished in quantity and contained numerous little collections of blood pigment. The kidneys showed no acute changes, but the fibrous tissue was markedly increased;

some of the epithelial cells lining the tubules were granular and others had separated entirely from the basement membrane. Hyalin casts could be seen in the tubules. The arteries of the kidneys were thickened; this thickening being most marked in the intima. The suprarenal glands and ovaries were negative. The specimen of the cervix showed round cell infiltration and some hyperplasia.

Microscopic changes found in the nervous system:

On examining the cortex stained by eosin and hæmatoxylin with the two-thirds objective, the most striking features observed were the thinness of the cortex, the unusual thickness of the first layer, the dilated state of the perivascular spaces, the great number of small, round, intensely stained nuclei, and the apparent proliferation of the small blood vessels, including the capillaries. The entire vascular system of the cortex and subcortical layer was markedly engorged and in the latter some extravasation of the cellular elements of the blood could be seen. Looking around the margin of the specimen just beneath the pia and in a few instances extending down into the cortical tissue, numerous little spherical bodies, a trifle larger than a leucocyte, palely stained and without well-defined nuclei, could be seen with the low objective. The one-sixth objective revealed considerable cell proliferation in the walls of the capillaries and arteries, with definite minute hemorrhages in the subcortical layer. The spherical bodies previously mentioned were found to be myelin globules and the numerous small, deeply stained nuclei seen with the low objective were thought to be the nuclei of the proliferated glia cells.

The nerve cells of the cortex as well as those of the cord (Nissl's stain) showed chromatolysis, shrinkage, granular degeneration, and in some instances, complete disintegration. In the cortex the greatest damage done seemed to be in the third layer, motor area, but the same condition was present in the other layers of the cortex as well as the other areas of the brain, to a less extent. Fat droplets were found in those cells which were partially degenerated; also scattered around between the cellular elements little black bodies could be seen which had taken on the osmic acid stain. Specimens from the various portions of the spinal cord, stained by the Weigert-Pal method, showed a diffuse fiber degeneration; the anterior and lateral columns suffering most. The fiber destruction in the cord was not in any place sufficient to entirely destroy its functioning power. The posterior columns were found to be in practically a normal state, possibly on account of having their seat of origin outside of the cord.

The above clinical and laboratory notes have been presented in as brief a form as practicable, therefore deductions are unnecessary. However, attention is called to a few particularly interesting features of this special case, such as the great number of relatives affected, the violent choreic movements, and the rapid mental reduction; also the extreme atrophy of the entire brain and the decided proliferation of the glia tissue elements.

BORDERLAND CASES OF INSANITY AND THE

VOLUNTARY PATIENT.*

BY ALBERT WARREN FERRIS, A. M., M. D., NEW YORK,
President of the New York State Commission in Lunacy.

Rarely does a physician experience as great satisfaction as that which attends the recovery of an insane patient. If skilfully adjusted occupation and diversion, special individual study and care, and personal suggestion result in the emergence of the patient, the medical attendant has received his highest recompense. Scarcely less valuable than his services are those of the physician who lifts to a higher plane the chronic case and makes the most for an irrecoverable patient of the remnant of life's enjoyment that is left him.

While relief from distress and cure of disease are generally considered by the thoughtless to be the whole duty of the physician, these do not in reality compass it; for prevention is the greater duty as it is the crowning achievement. Humanitarian, sanitarian, psychologist, and publicist the capable physician must be, and his arena is the world.

Over the entrance to the surgical amphitheatre of St. Come, Paris, are inscribed the words: "Ad cædes hominum prisca amphitheatra patebant, ut discant longum vivere nostra patent." That is, "The amphitheatres of old were open for the slaughter of men, ours that they may learn to prolong life." Not only to prolong life does the modern Esculapian enter the arena, not only to give successful battle to disease, but also to indicate undermining agencies, to avoid and remove causes of disease, and even to baffle heredity. This the psychiater of to-day accepts as his function and office.

We are led by habit of superficial thought, and by the subtle appeal of the artist to our emotional instincts, to accept the historic

*Read at the sixty-fifth annual meeting of the American Medico-Psychological Association, Atlantic City, N. J., June 1-4, 1909.