Multiple Sclerosis in Bosnia & Herzegovina

Abstract

 striking feature of multiple sclerosis in Yugoslavia, borne out by our clinical observations, is first of ali the limited extent of its occurrence. The disease is almost exclusively confined to the provinces of Slovenia and Bosnia, two,' predominantly mountainous and well wooded areas, similar to those found in Switzerland, Northern Europe, and parts of Germany and North America as well, where the disease is most frequently met with; therefore, it may well be that woodmand and forests tend to promote the spread of multiple sclerosis. At the same time, judging by the incidence oi the disease in this country, multiple sclerosis occurs not in regions with large tracts of high forest but rather in those of small young wood and shrubby trees, mostly along larger river valleys. Special geographical, thermographic factors which prevali in these regions appear to have a significant influence on the incidence of multiple sclerosis. The fact that most "rheumatic" diseases are to be found in these regions lends support to this view.

Moreover, we were able to establish — on the basis of our clinical matenial — characteristic seasonal variations in the morbidity of the disease. As shown by the the yearly rate of hospitalization, the maximum of morbidity occurs at the beginning of every 5th year; over the following four years there is a deeline coming to a minimum at the end of the 4th year.

Furthermore, important seasonal variations resulted from a stuđy of the monthly rate of hospitalization: the maximum of morbidity is reached in the months of April and November, which goes to show that multiple sclerosis studied under this aspect, too, is a seasonal disease occurring as it does during the periods of spring—summer andl autumn.

Our clinical data reveal the fact that both women and men contact the disease, the ratio beingl practically the same. With reference to the occupational factor, it appears that the disease attacks farmers rather than the townsfolk living in these areas.

Though the M. S. zone in Bosnia and Herzegovina comprises areas where syphilis is prevalent and endemic, we were unable — despite special efforts made to attain our end — to establish any connection between the two diseases, apart from the sameness of geographical extent and historical conditions of these areas. At the same time, among our cases there were patients that proved polysclerotic—syphilitic without the one disease creating immunity against the other, as e. g. in the case of syphilis and framboesia.

The clinical pictures of polysclerosis obtained under these specific conditions and with a special end in view, could not but show some divergence from the typical course and) development of this disease in other countries. Thus, in the greatest majority of cases, the disease u&ually starts with disturbances of sensibility followed by those of motility and finally by impairment of eyesight. The disturbances of sensibility and motility (5 p. c.) manifest themselves, at times, in unusually rare forms, such as astereognosis and genu recurvatum, but rarely met with in other countries, which is conditioned, in ouri view, by a historical course of events and a special way of life of the inhabitants of these regions.

In connection with these circumstances we were able to prove certain psychic disturbances in our patients to be the initial symptoms of polysclerosis, which is according to the datat available of rare occurrence in other countries. We are therefore of the opinion that the influence of psychic factors upon the development of multiple sclerosis has been unduly underestimated in other countries. The psychiic factor deserves, in our opinion, to be given a far wider recognition, the more so as the incidence of multiple sclerosis has been on the increase in ali countries, due to the new way of life after the two world wars.

On the basis of our factual material we would suggest that at the root of multiple sclerosis is a particular neuropathic predisposition which forms a fertile base for it — under the influence of a special pattern of various exogenous factors — to grow and develop into a specific disease. The specific nature of neuropathic constitution of tpolysclerotics, ali of whom invariably show a certain imperfection of the organism and personality as a whole, might be due to the fact that in the maturation process of CNS the myelination in certain places was not completed; that is why the process of demyelination most readily occurs in precisely these places under the influence of various exogenous factors. Once the hypothesis is accepted. the reason becomes clear for such wide and irregular dissemination of M. S. foci ali over the nervous system. It follows, as a matter of course, that in those parts where the myelination fails and remains incomplete the first to suffer among the CNS are those that are functionally under the greatest strain, which accounts for the difference in forms and course of the disease dependent on the way of life and harmful external influences met with in the regions concemed.

Besides the myelination distrubance of this kind, we can also assume the oase that the whole process of myelination suffers a check and remains definitely fixed at a lower stage of development so that, in this case of general immaturity and imperfection of myelination, diffuse forms of demyelinational involvement are most likely to develop; it is thus that multiple sclerosis and ali the other demyelination processes could conveniently be linked uP to form a chain.

Finally, in the entire course of this disturbance of CNS maturation the hypothalamus- hypophysali formations also seem to remain deficient, and it is the very insufficiency of these systems that plays one of the most important roles in the occurrence of multiple sclerosis.