On Nov 4, 1906, Alois Alzheimer gave a remarkable lecture, 1) in which he described for the first time a form of dementia that subsequently, at the suggestion of Emil Kraepelin, and 2) became known as Alzheimer’s disease. In his lecture, at the 37th Conference of South-West German Psychiatrists in Tübingen, Alzheimer described a patient called Auguste D, a 51-year-old woman from Frankfurt who had shown progressive cognitive impairment, focal symptoms, hallucinations, delusions, and psychosocial incompetence.
At necropsy, there were plaques, neurofibrillary tangles, and arteriosclerotic changes. The eponym Alzheimer, originally used to refer to presenile dementia, came into later use for the largest cause of primary dementia—senile dementia of the Alzheimer type (SDAT). Here, we describe the discovery and contents of the file of Auguste D, which had not been seen since 1909.
Alzheimer and Auguste D
Alzheimer was born on June 14, 1864, in Marktbreit, Germany, a small village near Würzburg. He studied medicine at the universities of Berlin, Tübingen, and Würzberg, where he wrote his doctoral thesis Über die Ohrenschmalzdrüsen (on ceruminal glands) in 1887, producing his first histological plates. In December, 1888, he began his medical career as a resident at the Hospital for the Mentally Ill and Epileptics, Frankfurt am Main, and subsequently was promoted to senior physician. Alzheimer’s research interests were wide ranging and included not only dementia of degenerative and vascular (arteriosclerotic) origin but also psychoses, forensic psychiatry, epilepsy, and birth control.
His interest in the neuropathology of dementing disorders was shared by his colleague Franz Nissl, who came to Frankfurt in March, 1889. It was Nissl who provided Alzheimer with new histopathological techniques for studying nervous disorders. On Nov 25, 1901, Auguste D was admitted to the Frankfurt hospital, where she was examined by Alzheimer. She had a striking cluster of symptoms that included reduced comprehension and memory, as well as aphasia, disorientation, unpredictable behavior, paranoia, auditory hallucinations, and pronounced psychosocial impairment. In 1903, Alzheimer left Frankfurt, and, after a short stay in Heidelberg, moved to the Royal Psychiatric Clinic, Munich, whose director was Kraepelin.
There, Alzheimer continued to follow Auguste D’s case until her death in Frankfurt on April 8, 1906, after which he went on to study the neuropathological features of her illness.
Auguste D and her file
On Dec 19, 1995, the 80th anniversary of Alzheimer’s death was commemorated at his birthplace in Marktbreit with the inauguration of his house as a museum and conference centre. Eli Lilly purchased the house, which has been renovated under the direction of Ulrike Maurer. Previously, we had conducted an intensive search for the file of Auguste D, which had been lost since its description by Perusini in 1909. We had been looking for it for many years; only 2 days after the 80th anniversary we found it in the archives of our own department in Frankfurt.
After 90 years, the blue-coloured cardboard file was still in good condition (figure 1); it contained a total of 32 sheets with the patient’s admission report, an attestation, and three versions of the case history—one in Latin script and two in the now outdated German “Sütterlin” script. The first Latin script, already published by Perusini and subsequently translated, begins with questions about her husband, followed by clinical findings, the details of the course of her disease, and a report on her death, including a histopathological diagnosis. The part written in Latin is followed by a nearly identical copy in Sütterlin.
A small sheet of paper with the handwriting of Auguste D dated by Alzheimer shows “amnestic writing disorder” so named by Alzheimer himself (figure 2). Alzheimer’s handwritten notes, also in Sütterlin, document in detail his patient’s symptoms during the first 4 days of her stay in hospital. In between Alzheimer’s notes are additional samples of Auguste D’s attempts to write her name. The file also contains four photographs of her (the most impressive is shown in figure 3) and a report about the course of the disease, which consisted of concise notes starting on June 29, 1905, and ending on the day of her death on April 8, 1906. Several attestations and an application form for hospitalisation of a mentally ill person together with a one-page case report from the Royal Psychiatric Department, Munich, conclude the file.
Figure 3 Full-size image (66K) Download to PowerPoint Auguste D Photograph dated November, 1902. Alzheimer’s notes in the file begin on Nov 26, 1901. He asked simple questions and wrote down Auguste D’s answers systematically. He resumed questioning on Nov 28, 29, and 30 on four handwritten pages. The file begins as follows (our italics denote Auguste D’s answers, and each translated passage is followed by figures of the original pages in the file):
Nov 26, 1901
She sits on the bed with a helpless expression. What is your name? Auguste. Last name? Auguste. What is your husband’s name? Auguste, I think. Your husband? Ah, my husband. She looks as if she didn’t understand the question. Are you married? To Auguste. Mrs D? Yes, yes, Auguste D. How long have you been here? She seems to be trying to remember. Three weeks. What is this? I show her a pencil. A pen. A purse and key, diary, cigar are identified correctly. At lunch she eats cauliflower and pork. Asked what she is eating she answers spinach. When she was chewing meat and asked what she was doing, she answered potatoes and then horseradish.
When objects are shown to her, she does not remember after a short time which objects have been shown. In between she always speaks about twins. When she is asked to write, she holds the book in such a way that one has the impression that she has a loss in the right visual field. Asked to write Auguste D, she tries to write Mrs and forgets the rest. It is necessary to repeat every word. Amnestic writing disorder. In the evening her spontaneous speech is full of paraphrasic derailments and perseverations.