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seem to show that, granted all the findings of an anatomical and, perhaps, chemical nature, dementia præcox is after all not a condition which can be placed side by side with the plainly organic diseases, such as general paralysis.
The last-mentioned author is perhaps influenced in his opinion by his studies of the personality in dementia præcox, I do not wish to convey the impression that studies of this kind are not important for the understanding of the psychoses, but it may be possible that too much stress has been laid upon the presence of defects of personality as an actual causative factor of dementia præcox. The part which the individual's personality plays in this psychosis cannot be disregarded. Nevertheless, one must be cautious in assigning to this one factor the unquestioned responsibility for the production of the disease. The character of the mental reactions may be influenced by the person's make-up, which is nothing more than the sum total of the individual's experiences. Character anomalies may, therefore, determine the type of delusional trends and the content of the hallucinations. About this there can be very little question.
But it may be possible that the precipitation of these reactions, together with the entire thought content of the psychosis, is secondary and incidental to the organic changes which occur throughout the body and particularly in the brain. What is meant can probably be best brought out by reference to certain observations recently made in a personality study of 36 cases of paresis published in the Journal of the American Medical Association (February 16, 1918, Vol. 70, pp. 434-439), in which we were able to suggest the great part that the personality plays in the character of the psychotic reactions in paresis. The conclusion which we reached from this study was that any one of several peculiar abnormal or neurotic types of personality existing in the syphilitic individual was liable to determine the nature of the paretic psychotic reaction. Paresis seemed to be capable for our purposes of being divided into two great groups. In one, not a small group, can be placed those cases characterized by rapidly increasing organic dementia and dilapidation of person and intellect without a psychotic reaction of definite type; and a second, a larger group, in whom the actual evidences of brain destruction, as expressed by the profound mental deterioration, were not at all marked especially at first, but in whom there existed a definite psychosis the nature of which might be either classed as paranoid, manic, depressive, euphoric or expansive. The first group was also characterized by the frequency with which physical signs of paresis were early encountered and were possessed of essentially normal, efficient personalities. Of the second group many went unrecognized until physical signs developed and disclosed the nature of the trouble. In this psychotic group the personalities were definitely abnormal. One of these cases which I reported is particularly instructive along these lines, for in one institution she was diagnosed as a case of dementia præcox, and in another she was considered to be manic-depressive insanity. It was only when physical signs in the pupils and changes in the reflexes made themselves so manifest that they could no longer be overlooked that any other diagnosis was considered. The diagnosis was confirmed by laboratory examinations of the blood and spinal fluid. Instances such as this are met, not only in paresis, but in the psychotic reactions of various types of neuro-syphilis and are highly instructive.
Schneider " has shown that in alcoholic hallucinosis definite "precipitating factors other than the alcohol are present and necessary in its production and are often reproduced in the psychosis.” Kirby,' referring also to alcoholic hallucinosis, states “in nearly every case .... one can establish that a definite emotional stress has immediately preceded the development of the hallucinosis; for instance, a threat, a quarrel, a fight, an arrest, imprisonment or some other annoying occurrence or actual cause for worry or anxiety." And in these cases Kirby remarks, " that the trend and hallucinatory content nearly always contains reference to the particular event which has disturbed the patient just before the outbreak of the psychosis." That this discussion is germane to our problem of dementia præcox can be seen from the fact that both Kraepelin and Bleuler have drawn a fairly definite analogy between the alcoholic hallucinoses and dementia præcox, although recognizing important differences, particularly in the recoverability of the former. Just as in the alcoholic cases the affects and other mental characteristics of the patient are exhibited in the delusional trends and hallucinations, so it may be in dementia præcox. The disturbing factor, whatever it may be, may act in some such manner. Hoch, Kirby and others have definitely shown the peculiarities of conduct and peculiar mental reactions which long precede the precipitation of the actual psychosis in dementia præcox. No one has, as yet, given us even a suspicion of the nature of the causative agent in the production of dementia præcox, but what occurs in the alcoholic hallucinoses might conceivably occur with some other toxic substance in dementia præcox, the resulting psychosis exhibiting in the delusional trends and hallucinatory content the peculiarities of personality of the individual. The analogy might be drawn even closer, for many cases of alcoholic hallucinosis when they clear up or have a recurrence show definite dementia præcox characteristics. Others, of course, simulate manic-depressive reactions. It is noteworthy that in individuals exhibiting either of these two types the personalities recognized as characteristic of these psychoses have been demonstrated as having been present long before the hallucinosis; but the alcohol and the emotional upset seems to be necessary for the production of the psychosis. The alcohol, therefore, apparently supplies the toxic material which causes quantitative and qualitative changes in the brain cells which are responsible for the symptoms of disordered mental function.
The influence of the personality of the individual in producing the type of psychotic reaction, whether it be in paresis, brain syphilis, chronic alcoholic hallucinosis or dementia præcox, cannot be questioned. That these peculiar personal characteristics are the primary cause of dementia præcox any more than they are the causative factor in these other conditions has not been proved definitely, despite the writings of the gentlemen quoted, or the insistence of other adherents of the psycho-analytic schools led by Freud, Jung and Adler.
It is necessary to call attention to the work of Southard," Nissl," Kleist," Alzheimer,' Sioli, Rosanoff," Morse," and others in order to bring the investigator into the question of the pathogenesis of dementia præcox to the realization that there is another than the psychological aspect to the problem. It may be useful to refer briefly to their findings. The clinical findings consist of tremors, changes in the reflexes, dermatographia, seborrhoea and certain eye symptoms. These last have recently been reviewed by Hoch and Teal.“
Hoch's review of the subject of the eye changes in dementia præcox shows, first, that they consist of the absence in a number of cases of the psycho-reflex; that is, dilatation of the pupils associated with mental activity, mental effort, affects, etc., and also in response to various sensory stimuli. Secondly change in the shape of the pupil and sluggishness to light reactions, especially in catatonic stupor. This symptom was called by Westphal catatonic stiffness of the pupil and is essentially a transient loss of light or accommodation reaction with changes in the shape of the pupils.
Abstracting the work of F. Reichmann, Hoch finds that her investigation showed 61 cases of dementia præcox with unusually large pupils and 31 with small pupils; 47 cases showed irregularities; eight cases demonstrated hippus and 30 cases presented anisocoria. She also found that in 215 cases of dementia præcox, ovarian pressure caused dilatation of the pupils 113 times, with some interference in the light reaction 29 times. The abstractor calls attention to the difference in these findings from that of hysteria. In hysteria, pupil dilatation occurs upon ovarian pressure without disturbance of the light reaction.
Teal found in 53 cases of dementia præcox dilated and tortuous veins and contracted arteries in the fundi. He also found various degrees of papillædema. He examined the fields in 15 cases of recent development. The charts showed concentrically contracted fields for form and color with frequent interlacing of the color fields. This contraction ranged from slightly less than normal to 30 degrees.
A brief reference ought perhaps to be made in passing to the various interesting, though not conclusive, studies in metabolism and in changes of the vegetative nervous system and the glands of internal secretion in this condition.
Of the metabolism studies, that of Ellison L. Ross" in five cases of dementia præcox is picked as a type. Ross quotes Pighini and Statuti as claiming that the metabolism is not normal in dementia præcox. Finding that various authors dispute this statement, Ross undertook the study in these five cases of the total nitrogen, sulphur, phosphorus, calcium and magnesium metabolism with their partition. Without going into detail as to the methods pursued, we find that he concludes the chief changes were found in metabolism of sulphur. These changes consisted of a diminution
of the amount of total sulphate, including the inorganic sulphate both in acute and chronic cases of dementia præcox, the amount of neutral sulphur excreted being above the normal. He, therefore, confirmed the finding of Pighini. He concludes that in acute cases the patients lose their normal powers of oxidation and suggests that the same condition prevails in the chronic cases. Attention is called also to the fact that the nervous system is richer in sulphate compounds than any other of the tissues of the body and that it has a high rate of metabolism in normal conditions. Other observers, particularly W. Koch, have found that the neutral sulphate is decreased in the brains of dementia præcox patients. It may be possible to refer with some profit also to the studies of various authors of the injection of adrenalin and pilocarpin in cases of dementia præcox. For instance, Neuburger,s on the action of adrenalin injection upon the blood pressure, says that in 80 per cent of the cases experimented with the reaction to adrenalin injection is diminished or absent. This refers to the influence on blood pressure and pulse rate. The exceptions to this rule were the paranoid cases studied and the excited cases with remissions who show a more nearly normal reaction to adrenalin. The number of cases studied was 63. As controls, 39 cases of various psychoses, neuroses and psychoneuroses were used.
Walter and Krumbach studied 18 cases of dementia præcox, four of which were chronic catatonic conditions, and three, chronic paranoid conditions, the others being more active types. They tested these cases with adrenalin, atropin and pilocarpin and found that only in the cases which showed chronic stuporous states were there any definite influences. In these cases adrenalin, atropin and pilocarpin had no influence on the blood pressure or pulse, and pilocarpin did not produce sweating. In the excited and paranoid conditions, the findings were inconclusive.
Brief reference might also be made (Dercum“) to the fact that the thyroid gland has been found enlarged in many cases of dementia præcox by various authors and that the body weight is generally below normal in this condition.
Alzheimer' definitely states that he is convinced that dementia præcox is an organic disease of the brain and he is inclined to regard the anatomical changes as definite. These changes consist of lesions in the second and third layers of the cortex characterized by sclerotic nerve cells, infiltration of cells with lymphoid sub