1924 The Practical Medicine Series - Comprising eight volumes on the year's progress in medicine and surgery. Volume eight: Nervous and Mental Diseases

Edited by Peter Bassoe, MD. Clinical Professor of Neurology, Rush Medical College of the University of Chicago. Chicago. The Year Book Publishers.

The Malaria Treatment of Paretic Dementia

"good results have been reported for nearly forty years with various forms of fever producing agencies of which malaria is now most popular" (p.141)

Reports on trials at St Elizabeth's Hospital, Washington, DC; the New York Psychiatric Institute; Nonne's Clinic in Hamburg; Bumke's Clinic in Leipzig, an asylum near Copenhagen in Denmark, and the National Hospital for Paralysed and Epileptic in London.


A noteworthy contribution is made by N. D. C. Lewis, L. D. Hubbard, and Edna G. Dyer (Amererican Journal of Psychiatry, October, 1924) of St. Elizabeth's Hospital, Washington, D. C.

They first give a historical review of the different treatments used, with special reference to fever treatment and particularly inoculation of malaria.

They quote A. Starcke as maintaining that fever induced by a method proposed by him is equally efficacious. An intramuscular injection of boiled milk is given in the morning. This causes considerable fever by evening, and then an intravenous injection of neoarsphenamin 0.6 to 0.9 gm., is given, which causes still higher fever. It is assumed that the fever renders the tissue more permeable to the drug-[On the other hand the worthlessness of this method is attested to by another author. See page 141, this volume. ED.]

A statistical review is given of 1,588 paretic patients admitted to St. Elizabeth's Hospital since 1886. Of these 1,144 were white men, 273 colored men, 69 white women and 72 colored women. Not less than 1,198 of these patients died in the hospital, and 22 others are known to have died since their discharge.

When it was decided to institute the malaria treatment in the hospital, 68 patients were selected and classified in three groups. In the first group were those who were in fair mental and physical condition, in the second group those who showed some deterioration as well as progression, and in the third group those who appeared almost hopeless from the standpoint of therapy. The patients were inoculated with tertian malaria according to the Wagner-Jauregg technic, allowed to have from twelve to sixteen paroxysms, and then treated with quinin. Nine patients failed to develop malaria and eight others soon left the hospital and no information could be obtained concerning them. Of the 51 patients who remained for observation, sixteen, or 31 per cent., had a complete remission_mental, physical, and serological. Nineteen patients were not notably changed, twelve went to extreme deterioration, and thirteen died. Necropsy was obtained in four of these cases and the brains were subjected to a detailed study, the main result of which was the demonstration of an apparent reduction in the plasma cell and lymphocyte infiltration of both meninges and perivas-cular spaces. At any rate, these brains exhibited far less exudate than the average paretic brain. Capillary hemorrhages and thromboses were marked in the brains of those who died at an early stage of the treatment. In two of the brains spirochsetes were not found and in the other two only a few damaged ones were demonstrated. In this connection it should be mentioned that, according to reports from the Wagner-Jauregg clinic, the brain picture in patients who died during the remission following malaria treatment resembled the so-called stationary paretic dementia of Alzheimer. Jossman and Steenarts report that seven brains from malaria treated patients were examined for spirochsete by Bielschowsky with negative results.

In the discussion G. H. Kirby stated that during the past year about thirty-five patients at the New York Psychiatric Institute were given malaria treatment, and so far the results appear encouraging as pronounced improvement has taken place in about 40 per cent, of the cases. In a series of 1,000 untreated cases of paretic dementia in the New York institutions spontaneous remissions occurred in 3.5 per cent, of the cases. Kirhy said that there was very little improvement in the physical signs in their cases, but there was serologie improvement in 75 per cent., although a completely negative Wassermann test with the spinal fluid was obtained in only one case. Of all reactions the colloidal gold test was the one most difficult to influence favorably. They did not find that serologie and mental improvement coincided. A pronounced gain of weight after the treatment was observed, the average gain being twenty pounds at the end of three months.

H. Reese and K. Peter, working in Nonne's clinic in Hamburg state that in this clinic no good results had been obtained in paretic dementia by tuberculin injection, the nonspecific protein treatment, or with intravenous, intracarotid, and intraspinal arsphenamin treatment. They were, therefore, glad to try out the malaria treatment. Since June 1920, 236 cases of clinically certain paretic dementia have been treated. From 5 to 10 c.c. of blood were removed, under sterile precautions, from an arm vein shortly before the height of the febrile attack and defibrinated with 0.1 c.c. of a 50 per cent, dextrose solution. If the defibrinated blood is to be transported for a long distance, it may be kept in a thermos bottle at body temperature as long as 13 hours providing shaking is avoided, as this tends to cause the plasmodia to separate from the blood corpuscles and die. Of this defibrinated blood 0.5 to 1 c.c. is injected subcutaneously. However, when injections could be made directly from patient to patient in the hospital, the blood was often injected directly and intravenously without being defibrinated. The period of incubation was usually from ten to 25 days after subcutaneous injections, and from five to eight days after intravenous injection. The authors warn against the use of this treatment in elderly and decrepit patients, and they also insist on the importance of those giving the treatment having a thorough knowledge of the manifestations of malaria. A danger of accidental inoculation of tropical malaria exists when blood is taken from a donor coming from the tropics, even if only tertian or quartan organisms are found in blood smears. The blood should be examined daily, and for several days, before the particular donor is used. [Last year I visited a European clinic where this very accident happened. A malarial patient had been secured and was certified by the department of medicine to have tertian malaria, yet two paretics inoculated with his blood developed tropical malaria, with fatal result in one._ED.]

Out of 236 treated cases the authors select for report 75 cases which have been followed up since the termination of treatment one and one-half to two years prior to writing the article. Thirty-eight of the patients (50.6 per cent.) were in remission and back at work, fifteen (20 per cent.) were nearly well and able to work, 22 (29.4 per cent.) remained unimproved. Up to the time of writing, 25 of the 236 patients had died, and in seven of these the malaria itself was apparently the immediate cause of death. As to the laboratory tests, the blood Wassermann became negative in seven cases and spinal fluid Wassermann in five. The speech disturbance disappeared in several cases; in one, even an Argyll-Robertson pupil.

From Denmark V. Askgaard reports that in October, 1922 two patients from an asylum near Copenhagen were taken to Vienna for inoculation with tertian virus, and since then it has been kept alive by passage from patient to patient. The treatment has been given to 37 paretic patients, twelve of whom (32.4 per cent.) had full remission and eight (21.6) per cent.) partial remission. If six advanced cases which were used merely to keep the strain alive are excluded, the percentages will be still better, namely 38 for full and 26 for partial remission. No deaths were attributed to the treatment, but several times it had to be interrupted on account of threatened collapse.

Experience with eighteen comparatively early cases observed at the National Hospital for Paralyzed and Epileptic, in London, is related by H. J. Macbride and W. L. Templeton. They are not as optimistic as most of the continental users of the method. They admit various complications during the treatment, including three deaths. Among the others were urinary retention, vomiting, nose-bleed, and herpes. In the first fatal case the patient, six hours after inoculation with 2 c.c. of benign tertian malarial blood, had a convulsion and the temperature rose to 107° F. He then immediately went into a status epilepticus, followed by a semi-comatose condition, and death followed six days later, in spite of intravenous quinin treatment. The second patient died after a period of progressive prostration and refusal of food, while the third one had daily rigors with cyanosis and great aggravation of the pre-existing tremor of the hands, the movements finally resembling clonic convulsions. In the last two cases necropsy was obtained and both showed marked splenic enlargement and bile staining of the liver substance, so that it was thought that death was due to malarial infection.

By way of summary, it is stated that in two cases of juvenile paretic dementia (due to congenital syphilis) no improvement was noted, which is in agreement with the experience of Weygandt in Germany. Of fiye chronic cases, one died and four showed some degree of improvement, one, however, quickly relapsing. In another, auditory hallucinations which were acquired during the course of the fever still persisted after an interval of four months.

Of eleven early cases, two died during the treatment. Three showed very marked mental and physical improvement although two of them had been temporarily worse mentally immediately after the treatment. Three showed considerable physical improvement, one very slight improvement, one grew decidedly worse, and another showed slight mental improvement but grew worse physically and died after four months.

Ilse Graf reports on the experience at Bumke's clinic in Leipzig where malaria treatment of paretics was instituted in 1921. Of the seven patients treated in 1921, one had a complete remission, with perfect mental restoration and return to the former occupation, and four had partial remissions, while two still persisted. One patient was not influenced by the treatment and later died. The seventh patient has remained unchanged, but in his case there is some question as to whether he has tabo-paresis or tabes with an alcoholic psychosis.

In July, 1923, twelve more patients were treated. Two had definite remissions, two others were improved, and the others were not benefited. In two cases the speech disturbance has disappeared, otherwise there has been no restoration of any lost bodily function. In five cases the cell count of the spinal fluid has become normal, in two cases the blood Wassermann , and in one, the spinal fluid Wassermann tests have become negative.




Institution Statistics According to Official Figures
Public Health Report July 25, 1924.

On January 1, 1923, patients in public institutions of the United States numbered: insane hospitals, 290,457; psychopathic wards of general hospitals, 1,842; institutions for feeble minded, 46,722; institutions for epileptics, 9,153. In addition there were confined in federal penitentiaries, 2,010; in state prisons, reformatories, etc., 19,518; in county and city jails, workhouses, etc., 147,489; in institutions for juvenile delinquents, 29,385.

Rather disconcerting figures have been assembled by H. M. Pollock (American Journal Pyschiatry, January, 1924), statistician to the New York State Hospital Commission. From 1880 to 1920 the number of insane patients of institutions in the whole country has increased from 40,942 to 232,680 and the ratio of patients in institutions to 100,000 of populations from 81.6 to 220.1. This, of course, does not mean a proportionate increase in insanity as a much larger percentage of insane patients now is confined in institutions.

While there undoubtedly has been some general increase in insanity, this, like the apparent increase in cancer, is mitigated by various factors. For instance, during the 40-year period here considered, the average length of life in the United States has increased from 41 to 56 years. This means that hundreds of thousands of children and young people who previously would have died from infectious diseases now live long enough to develop insanity. One other factor which tends to increase the number of patients is the constant increase in urban population, which was 28.6 per cent in 1880 and 51.4 per cent in 1920. The average annual rate of admissions to insane hospitals from cities is 69.5 per hundred thousand and from rural districts, 42.5 per cent. It is further seen that the rate of dementia praecox admissions is 19.1 for cities and 7.8 for country; of general paresis, 9.8 and 2.9 respectively; of alcoholic psychosis 3.7 and 1.6. The number of senile psychoses from the country districts is greater, undoubtedly because more people reach old age there.

It is gratifying to note that in the state of New York there is a marked decrease in the proportion of alcoholic psychosis and a considerable decrease in general paresis. Pollock states that the movement to check the spread of syphilis which acquired impetus during the war and has since been continued has great significance in the field of mental health.

One important principle is that the rate of mental disease is greater among inferior stocks than among superior stocks. This is difficult to demonstrate by census statistics which take no account of the quality of family stock. The general birth rate in late years has markedly declined and it is generally believed that the decline has been greatest among superior stocks. If this trend continues, the people of the future will become more and more susceptible to mental disease.

Another general factor the author describes is the economic condition of the people. Mental disease declines in times of prosperity and increases in times of adversity, and Pollock adds that the tendency in this country being toward general stabilized prosperity with shorter working days, better conditions of employment, and higher standard of living, the economic outlook for mental health is good.

The rates of dementia praecox and manic-depressive psychosis are both increasing, and if nothing is discovered to curb these diseases, while new discoveries continue to be made in the realm of bodily disease, then mental disease will supersede physical disease as the paramount social problem in the not distant future.

Constitution and Disposition in Relation to Mental Disease.

A concise and thoughtful discussion of this difficult subject is contributed by A. M. Barrett. (American Journal Psychiatry, October, 1924).

We wish particularly to call attention to the following review by him of recent work on the "cyclothymic" or "syntonic" and "schizothymic" or "schizoid" types largely because it gives a clear account of the important work of Kretschmer. (An explanation of these terms and of the chief theories of Bleuler and Kretschmer was given in this Series, 1922, vol. 8, page 293.)

Barrett states that it is in relation with the two great psychotic groups of cyclothymia and schizothymia that the question of constitutional dispositional relations has recently gained particular interest. In the progressive development of conceptions of the nature of the manic- depressive psychosis, increasing attention has been given to its underlying constitutional aspects. Its hereditary relationships and the characteristics that show in the cyclothymic life course in this disorder are evidences of some fundamental specific quality that must lie in the constitution of the individual.

The constitutional and dispositional relations of schizophrenia have been later acquisitions to our knowledge. The study of families in which schizophrenia occurs has shown that there are abnormalities of constitution that seem to stand in some hereditary relation to the disorder. The recognition of the abnormalities commonly observable in schizophrenic individuals in pre-psychotic phases, the recent concepts of schizoid qualities of character and temperament, and the physiological and somatic disturbances associated with the progress of this disorder, have forced upon us the conception that in schizophrenia, constitutional and dispositional qualities are of fundamental importance.

The author believes that interest in this problem of constitutional relations in both cyclothymia and schizophrenia has been stimulated by the recent contribution of Kretschmer who in his monograph on Körperbau und Charakter has presented data and viewpoints that gives us a new orientation in this field. In clear formulations of what is involved in the concept of constitutional factors the latter author puts forward theories and points of view regarding correlations of somatic and psychic relationships that have an application not only in the psychoses but also in a wide range of interests dealing with human qualities and temperament.

A study of the physical characteristics of the body in cases of cyclothymia and schizothymia leads Kretschmer to the formulation of a theory that in each of these groups of psychoses definite types of physical constitution are in relation with specific psychic qualities. He finds that in schizothymia there is a marked preponderance of body structures that are of asthenic, athletic or dysplastic endocrinopathic types or intermixtures among these. In cyclothymia the dominant quality of body is of a thick-set or pyknic type. The characteristics of these contrasting types are evident not only in the general structure of the body frame, but in the quality of the body surfaces. It is his belief that the psychic constitution of an individual expresses itself not only in its psychological qualities, but also in the comprehensive manifestations of his entire personality in all of its life phases and that the endogenous psychosis is but an episodic and partial segment. These correlations exist also in non-psychotic individuals and can be shown to be determining factors in their personalities and in the quality of their creative energies.

The individual constitution as formulated by Kretschmer

"is the totality of all the individual characteristics that are based on heredity. Constitution has its psychic correlations in character and temperament. Character is the totality of all the reaction possibilities of an individual that are regulated by his affective volitional functioning. Character is a matter of the affective life. Temperament is conditioned by the blood humoral chemistry and their physical correlate is the brain-gland interrelations."

Qualities of temperament are essentially influenced by the endocrine system. As evidences of this Kretschmer comments on the well-known abnormalities of temperament that occur in states of hypo- and hyperthy- roidism and after sex gland castration. These correlations of body habitus and temperament suggest that the temperament types characteristic of cyclothymia and schizothymia have similar correlations with humoral relations. They are concerned with the entire blood chemistry of the body. There thus exists not only a parallelism between brain and psyche but also some and psyche. In schizothymia the facts seem to indicate that there exists a complicated dysfunctioning of the sex glands in correlation with the entire endocrine apparatus and brain. On the other hand, in cyclothymia the characteristics of the individual's constitution seem to be in correlation with the glands controlling the general nutrition of the body. Here also there may be a humoral relation.

The temperaments according to Kretschmer, apart from their central relations are dependent upon two great hormonal groups. One of these acts in relation with the diathetic states or the nutritional metabolism of the body, and the other on the psychesthetic or affective balances. In the average individual these two groups of hormones are mixed in changing relations, but in cyclothymia or schizothymia one or the other has gained a dominance; the diathetic in cyclothymia and the psychesthetic in schizothymia. This dominance may have been determined through inherited qualities or developed through selection in family inter-relations. That these qualities do have relations to family inheritances has been shown in the studies on heredity by Riidin, Kahn, Hoffman and others.

In his conclusion Barrett states that it is these two contrasting constitutional qualities that are embodied in the concepts of schizoid and cycloid, or as discussed by Bleuler, schizoid and syntonic. With a viewpoint that harmonizes with the conceptions of Kretschmer, Bleuler presents the theory that every individual has in his anlage a schizoid and syntonic component. Normally these exist in an equilibrium, but conditions may occur that give dominance to one or the other of these in quality of the psychic reactions. One not infrequently observes the two qualities intermingling in a psychosis to produce such atypical clinical reactions as "schko-mania," and "cycloid-schizophrenia." In psychoses of exogenous origin one may sometimes recognize the temperamental characteristics of these two conditions determining the reactions and symptoms during the course of the disorder. Thus Binswanger has published an interesting study on schizoid reaction in alcoholics.

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