Alzheimer's disease existed before 1906, but until that time it did not have a name. Senility was the name given to the mental impairment of the elderly. This senility was not considered to be a disease, but the natural consequence of aging, like wrinkles and graying hair, something that would happen to most if not all persons as they aged. The word senility comes from the Latin word senium, which simply means old, as opposed to juvenile, which means young. Because of its prevalence in the elderly, senility came to mean the mental impairment of old age; old age became synonymous with senility.
The Meeting of Dr. Alzheimer and Frau Auguste D.
When Dr. Alois Alzheimer, a young German neurologist, examined Frau Auguste D. in November of 1901, he was unable to diagnose her strange symptoms and behavior. In all his medical training and experience he had never seen a case like hers before. It wasn't that he hadn't seen her symptoms before. He had. He had often seen the memory loss, the difficulty with speech, the confusion, and the inability to reason in the very old and senile, people thirty to forty years older than Frau Auguste D. But what was considered perfectly normal in someone of eighty or ninety was not normal in someone of fifty-one. It was as if a young woman of twenty were to have all the signs and symptoms of menopause. These signs and symptoms are normal, natural and expected in a woman of fifty, but not in a woman thirty years younger.
So Dr. Alzheimer was perplexed as the woman's husband described his wife's unusual behavior over the last several months. That behavior was a classic, textbook case of the symptoms of Alzheimer's. This is not surprising since the case of Frau Auguste D. is the classic case that the textbooks are based upon.
According to her husband, she would forget where she put things, then fly into a rage when she couldn't find them and accuse him of stealing them and hiding them from her. Sometimes he would find things in bizarre places. One time he found her hairbrush in the oven; another time he found his pipe among the laundry clothes.
She had become irrationally jealous, accusing him of being unfaithful to her with no grounds or justification for such suspicions. She would have violent and explosive outbursts of temper, which were completely out of character for her.
Several times she became lost when she went shopping in the neighborhood, where she had shopped for years, and could not find her way home again. Worse still, she became confused and disoriented in their apartment - she couldn't remember where the bathroom was.
She forgot the names of simple household objects such as the bed or the icebox. She would substitute a functional description of the word rather than the precise word itself. For example, she would say milk jug instead of cup.
She could no longer cook. She could not remember recipes. She couldn't remember what pots and kitchen utensils were for. She couldn't set the table. She even had trouble dressing herself.
Her sleep had been getting worse over the months. As nighttime approached, she would become even more agitated and confused. When she finally did fall asleep, she often awakened later and left the bed to wander about the apartment.
From the symptoms that her husband described, Frau Auguste D. seems to have been in the middle stages of the disease when he brought her to the mental asylum in Frankfurt on a cold November afternoon in 1901. Although Dr. Alzheimer could not make a diagnosis, it was nevertheless clear that Frau Auguste D. had a rapidly progressive mental disease and could no longer be cared for at home. He signed the admission papers, and she was admitted into the hospital.
Final Stages And Death
The remaining four and a half years of her life were spent in this asylum where she progressed to the severe and final stages of the disease. She did not know where she was or who she was and, after several months, failed to recognize even her husband or her daughter. She wandered the halls of the hospital constantly, dragging sheets and bits of bedding, calling for help. She couldn't remember where her room was, nor was she able to recognize Dr. Alzheimer on his rounds.
By November 1904, three and a half years into her illness, Frau Auguste D. was bedridden, incontinent, and largely immobile. The following year she had become permanently curled up in the fetal position, with her knees drawn up to her chest, muttering but unable to speak, and requiring assistance to be fed. After four and a half years in the hospital, Frau Auguste D. died on April 8, 1906 at the age of 55. Her file listed the cause of death as "septicaemia due to decubitis" - acute blood poisoning resulting from infectious bed sores. In her last days, she had pneumonia, inflammation of the kidneys, excessive fluid in the brain, and a high fever.
Discovery Of The Plaques And Tangles
As a result of a newly developed high-resolution microscope and a revolution in tissue staining, Dr. Alzheimer was able to study the cells and tissues of the brain. What he saw in the brain of Auguste D. shortly after she died in 1906 were the characteristics of a new dementia. Between the nerve cells (neurons) of her brain, Alzheimer observed what he termed "peculiar formations" or "plaques." He had seen these unusual plaques before, in the brains of the very old; they were called senile plaques. Inside the nerve cells he observed what he called "tangled bundles of fibrils." Finally he observed that many neurons were simply missing: he could see the empty sites where they had once been.
The "peculiar formations" are now called amyloid plaques, and the "tangled bundles" are now called neurofibrillary tangles. It is believed that the amyloid plaques attack the brain cells from the outside, while the neurofibrillary tangles destroy them from the inside.
These three pathological changes in the brain - the loss of brain cells, the amyloid plaques, and the neurofibrillary tangles - were Alzheimer's chief findings after he examined Frau Auguste D.'s brain. A century later, they remain the basis for the microscopic diagnosis of the disease, which can still be definitively diagnosed only after death.
When Alzheimer announced his discovery of this new disease in November 1906, he was met with indifference. It was accepted as a new disease but a very rare one, a presenile dementia affecting a tiny number of people in their forties and fifties. It was called "presenile dementia of the Alzheimer's type" and was believed to be entirely different from the senile dementia affecting the elderly, which was not considered to be a disease at all.
It wasn't until 50 years later that these two dementias were proved to be the same. And it wasn't until 70 years later that the medical establishment accepted senility as a disease and not an inevitable consequence of aging. The story of how this discovery was made and how it finally became known and accepted will be the subject of next week's column.
Mary Lou Williams, M. Ed., is a lecturer and writer in the field of nutrition. She welcomes inquiries. She can be reached at 267-6480.