Autopsy: Death from hypostatic penumonia. Healed gastric ulcer. Moderate arteriosclerosis, slight cardial hypertrophy. Granular cystic kidneys. Mucous polyp and subperitoneal fibromyoma of uterus. The brain was macroscopically normal, but showed superficial gliosis (frontal and precentral) and thinning out of medullated fibers superficially (frontal).
CASE 20. (D. S. H. 8963, Path. 679) an epileptic shoe-maker, 50 years, was of the belief that he was sent to Hospital for hitting a boy and was to be executed.
Autopsy: Aortic and innominate aneurysm, hypertrophy and dilatation of heart. Interstitial nephritis. The brain, normal macroscopically, proved microscopically to show, in all areas examined, superficial gliosis. There was gliosis in parts of the cornu ammonis, but no demonstrable nerve cell loss (interesting in relation to the epilepsy).
CASE 21. (D. S. H. 4584, Path. 861) cabinet-maker of melancholy temperament, Civil War veteran. Said to have been feeble-minded after six months in rebel prison. Violent at times for twenty years. Did no work, thought "soul lost."
Death from pneumococcus and streptococcus septicemia. Chronic diffuse nephritis. The brain was described grossly as normal: but microscopically there was marked superficial gliosis in all areas examined and considerable cell loss in suprastellate layers of precentral cortex. The calcarine sections show little or no cell-loss. But one section from the frontal region is available (right superior frontal). This shows little cell-loss except in the layer of medium-sized pyramids.
CASE 22. (D. S. H. 8250, Path. 909) an unmarried woman without occupation, two attacks of "melancholia" at 36, and 40. Always of a retiring and shy disposition. Mental disease began after father's death. Delusions (if such): has been selfish and wicked. Constant self condemnation. Suicidal. Exophthalmic goiter.
Autopsy: Thyroid glandular hyperplasia. Mitral sclerosis. Aortic sclerosis with ulceration. Chronic endocarditis. Chronic diffuse nephritis. Scars of both apices of lungs, with small abscess of left apex. Emaciation. Brain weight 1050 grams. No gross lesions described; microscopically profound alterations; extreme or maximal cell-losses in small and medium-sized pyramids in both superior frontal regions. Smaller somewhat less marked cell-losses elsewhere.
Upon reviewing the unpleasant-delusion group, then, we exclude one (XII) altogether. It is questionable whether XV actually exhibited delusions at all. We then discover that eight (in all probability all) of our nine remaining cases are renal in the sense of grossly evident lesions at autopsy.
But it will be remembered that we transferred three cases originally thought to entertain "not-unpleasant" delusions to the unpleasant group, because their constraint, although conceived to be of divine origin, seemed to be unpleasant (VI, IX, X). Of these VI and X were renal cases; but IX is expressly stated by a reliable observer (the late Dr. W. L. Worcester) to have had normal kidneys as well as heart. In point of fact, however, Case IV had hallucinations and religious delusions ("spirit is here") probably derived therefrom, and Dr. Worcester found an isolated brain lesion correlatable with the hallucinosis; and in any event the emotional state of the patient is in grave doubt.
Accordingly if we take the unpleasant-delusion group to be constituted of Cases VI and X (transfers from the first group), XIII, XIV, and XIV to XXII, that is eleven cases, we come upon the striking fact that virtually all of them are renal cases.