The patient had been engaged in the Treasury Department in Washington for about 40 years; her duties compelled her to handle a considerable amount of money in paper form, and it was first thought she might have absorbed sufficient of the metals in the print to account for the neuritis. It was learned, however, that her occupation was one concerned with dilapidated and almost unrecognizable paper currency, and it is certain that whatever amount of ink could have been removed from the bills had already been removed by constant handling before the bills were placed in her hands.

Poisoning from foods, drinking water, etc., can not be excluded absolutely, but there is nothing in the history or in the conditions of life of the patient that definitely points to anything of this sort. The absence of any quantity of similar patients in Washington leaves a supposition of this sort without any foundation. We are left, therefore, to conclude that the cause of the neuritis was something within the body, of the nature of a toxin, but we do not care to speculate on the location and the origin of the toxemia. Similar conditions have been described under the name of idiopathic multiple neuritis. There have been published reports of cases in which the neuritis was caused by diabetes, typhoid and typhus fevers, and Ballet and Rose describe a case in which they assign as the cause "alimentary intoxication." We are well aware that the use of the term "autotoxic" is an indication of our ignorance rather than of our knowledge, but, in view of any assignable cause, this term may be used with the probability of comprehension on the part of the reader.

CLINICAL AND ANATOMICAL ANALYSIS OF 23 CASES OF INSANITY ARISING IN THE SIXTH AND SEVENTH DECADES WITH ESPECIAL RELATION TO THE INCIDENCE OF ARTERIOSCLEROSIS AND SENILE ATROPHY AND TO THE DISTRIBUTION OF CORTICAL PIGMENTS.*

BY E. E. SOUTHARD, M. D.,

Assistant Professor of Neuropathology, Harvard Medical School;
Pathologist and Assistant Physician, Danvers Insane Hospital,

AND

H. W. MITCHELL, M. D.,

Superintendent of the Eastern Maine Hospital for the Insane, Bangor; formerly Senior Assistant Physician, Danvers Insane Hospital.

(From the Pathological Laboratory of the Danvers Insane Hospital.)

sixth and seventh decades...

VI. (a) The relation of arteriosclerosis to insanities arising in the

(b) The relation of senile atropic processes thereto...

328

330

(c) The distribution of cortical pigments in these cases.

331

334

VII. Conclusions

*Read at the Annual Session of the American Medico-Psychological Association, Cincinnati, May, 1908.

I. GENERAL STATEMENT.

The diagnosis of mental disease is not anywhere more difficult than in persons attacked in the fifth, sixth and seventh decades in life. This difficulty is paramount in the fifth decade, particularly in women, and is assumed to be connected with altering processes of growth and internal secretory changes. The problems shift their ground in the sixth and seventh decades and are particularly complicated by the suspicion of premature old age changes.

We have chosen to analyze the clinical and anatomical material, accessible to us, from cases developing or assumed to develop insanity in the sixth and seventh decades. We have been looking, consequently, toward the relation of these phenomena to senile phenomena rather than to the more complex or obscure conditions of earlier decades.

We have omitted cases of dementia paralytica, cerebral tumor, and extensive focal brain lesions from consideration in this group. The 23 cases here presented occurred in a series of 472 autopsied cases (1902-1907) at the Danvers Insane Hospital and were chosen on the ground of probable onset of mental disease in the sixth or seventh decade, as shown by reference to case-histories. All the cases had been observed by one (or both) of the writers or (in a few instances) by assistant physicians who were personally consulted concerning the fitness of these cases for the chosen group. The 23 cases represent a sifting out from about 50 autopsied cases which were thought at first to correspond to our criteria but were found actually to represent instances of paralytica dementia or other coarse brain disease. A few cases, clinically appropriate, were omitted on account of deficiency in the anatomical records. The group represents about 5 per cent of the autopsies performed.

II. CASE MATERIAL.

We present 23 cases of insanity arising in the sixth or seventh decade. The clinical histories are much condensed, and the autopsy protocols are given in summary form. These cases are arranged according to a tentative grouping, adopted for convenience at the outset :

Case I is a man whose insanity developed at 57 and who died at 63, after five years in the hospital.

No history of neuroses, psychoses or intemperance in immediate family. He was a bright companionable man in early life and since boyhood had been intemperate in the use of alcohol. Because of drinking habits, he failed in his business as undertaker one year before admission. He continued to drink hard and became much demented. He had no memory for recent events and showed well-marked fabrication.

On admission he was well nourished. Physical examination was negative excepting for sluggish pupillary reactions and diminished tendon reflexes. There was no history of lues.

He was neat and orderly in manner, and talked coherently in response to overtures, but there was practically no spontaneous production. He was disoriented for time, place, and persons. His memory was almost a blank, and he fabricated to supply deficiency. He was not hallucinated and never showed any well-defined delusions. He had no grasp on surroundings or any insight, and was always amiable. He never showed any interest in surroundings or engaged in any work or amusement of his own initiative. There was no apparent change in his mental condition before death.

Anatomical Diagnoses.

Chronic valvular endocarditis.

Calcification of bronchial lymph nodes.

Ulcerative colitis.

Slight aortic sclerosis.

Cysts of kidneys.

Weight of brain, 1250 grams.

Case 2 is a man whose mental trouble developed gradually at 63 and who died at 65, after one month in the hospital.

One aunt was insane. One of his four children died of convulsions. The family history was otherwise negative.

He was said to have had average mental ability and was of a cheerful temperament. All his life he had been addicted to excessive use of alcohol and had for over two years shown gradually increasing mental and physical failure with several attacks of hallucinatory delirium. One month be