Hans Förstl


Alois Alzheimer

Die arteriosklerotische Atrophie des Gehirns.

Allg. Z. Psychiat. (1895)  51, 809-811 

Arteriosclerotic brain atrophy.

A model of the Hachinski “ischemic score” for  "multi-infarct dementia".

Among the many disturbances of the senium there is one which can be distinguished easily from general paralysis both by its clinical features and even more so by its pathological appearances, that is, arteriosclerotic degeneration. This disease affects particularly individuals between the ages of 45 and 55 and males more than females. Generalized arteriosclerosis* is always to be observed. Aetiologically, in no case has syphilis been demonstrated. However, the disease can in part be attributed to the habitual consumption of large amounts of fluids, not so much those with a high alcohol content but more often beer and apple-wine. Occasionally there appears to exist a hereditary disposition for arteriosclerosis (apoplexy). My observations relate to 12 cases. The prodromal stage may last for many years and manifest itself first with headache, * vertigo, * fatigue and increased irritability. Soon a failure of memory becomes noticeable and this is usually very embarrassing for the patient. Sometimes there are episodes of transient anxious excitement* which are accompanied by cardiac or vascular phenomena. * It was also observed that the condition can start with a sudden apoplectic attack* from a state of normal mental vigour. The further course is characterized by an increasing failure of memory and judgement. Obvious delusions do not occur as a rule. The basic state of mind may consist of a mild euphoria and plaenomachia or a hypochondriacal mood* with very deep insight into the disease. Generally the affect varies to some extent. Until its late stages the disease can easily be distinguished from general paralysis by the patient's tranquillity, orderly conduct*, intelligence and ability to reason*, which is only lost du ring attacks of excitement. Sometimes the intelligence is relatively preserved until the end, sometimes an apathetic idiocy resembling that seen in the final stages of paralysis may develop. Sometimes memory seems completely erased but the patient knows how to behave in a reasonably orderly manner*. Apoplectic attacks* may occasionally interrupt the course. The most commonly observed physical features* are the early development of severe tremor, weakness of the lower extremities and an exaggeration of the patellar reflexes. The pupillary reflexes are regularly affected but only late in the course of the disease. A disturbance of language, somehow different from that seen in general paralysis, is always observed. In more than half of the cases hemiparetic features were to be found, and one case a hemiplegia with spastic contracture. At autopsy one can, as a rule, find an arteriosclerotic wasting of the kidney as well as arteriosclerotic degeneration of the vascular system. The pia shows a relatively mild opacity and the brain little atrophy. The cortex appears narrowed to a lesser degree than the white matter, which is traversed by yellow stripes representing blood vessels. The fresh brain exhibits broad fluid-filled spaces surrounding the vessels, which can be picked up in long pieces with a forceps. The addition of hydrochloric acid releases large amounts of carbonic acid. These perivascular spaces are largest in the basal ganglia and in the internal capsule. The microscopic examination of the brain demonstrates small aneurysms in the cortex. numerous little haemorrhages and in addition there are focal glial proliferations in the vicinity of the most degenerated vessels. Even in the cases in which a spastic hemiparesis had developed, there was no macroscopically detectable haemorrhage in the internal capsule. However, in these cases the focal proliferations of the connective tissue described above were observed around the degenerated vessels and these were similar to the alterations in the cortex and in the hemispheric white matter. This finding may perhaps explain the presence of hemiplegia in patients with arteriosclerosis which Jacobson recently described in a summary in the Zeitschrift für Nervenheilkunde. Hitherto, cases of arteriosc1erotic brain atrophy were included with general paralysis and with the changes in the early and late stages of senile dementia. Histologically, however, the focal character of their degeneration is essentially different from the diffuse changes of paralysis and also from those seen in the early stages of dementia senilis. Even the clinical course taken by itself is so different that there is good reason to separate arteriosclerotic brain atrophy from other brain disorders and to consider it as an independent disease. 

* Features of vascular dementia according to Hachinski et al. (1975)

(Translated by Hans Förstl and Ramond Levy.
This paper is naturally marked by the preoccupation with the separation of arteriosclerotic dementia from general paralysis of the insane since he was writing at a time when syphilis was considered the most common form of presenile dementia. He shared the concerns and aims of Binswanger (1894), whose name is now associated with subcortical vascular disease. Both here and in his later publications, Alzheimer gave clear clinical guidelines which might allow his contemporaries to distinguish vascular dementia from general paralysis and senile dementia. The paper was presented at the yearly congress of the Society of German Alienists in Dresden in 1894 and published in the Allgemeine Zeitschift für Psychiatrie 1895).