Biographies de neurologues
Nouvelle Iconographie de La Salpêtrière
 L'histoire des neurosciences à La Pitié et à La Salpêtrière J Poirier
The history of neurosciences at La Pitié and La Salpêtrière J Poirier 

mise à jour du
25 octobre 2007
Case report II
p 63-72
Postencephalitic respiratory disorders
Jelliffe SE
27/10/1866 - 25/09/1945
Constantin Van Economo


Part III page 73-100
Miss Y. was referred to me on February 8, 1926, by Dr. L. Loeb of Philadelphia through the suggestion of Drs. W. G. Spiller and A. M. Ornsteen of the same city.
At this date she was twenty-six years of age, single. The family history is of interest. The father was born in Germany of Jewish parentage. He has a distinct psychoneurosis, chiefly gastrointestinal in its manifest content. The mother wàs born in the United States of Jewish parentage. There are three children in the family -a son of thirty-three, married, with two children, reported healthy; a son of thirty-one who had a encephalitis while in the navy serving in the World War and has been psychotic for, at least five years, diagnosed as "dementia precox type"; the patient is the youngest child.
There are other family disturbances in addition to the father's neurosis and that already outlined for the brother. llly defined histories of two psychotic members of the mother's family are indirectly learned of. There is no history of diabetes, goiter, endocrine anomalies, tuberculosis, nor alcoholism on either side thus far obtainable.
Personal history: The patient was normally born, walked and talked at the usual period, read at the age of five to six. She has remained a thumb sucker to the present time, using the middle and ring fingers of the right hand. She had whooping cugh at the age of seven months, measles, chickenpox and diphtheria at five. She had no history of infantile enuresis, did bite her finger nails, did not walk in her sleep, but did talk in her sleep. There is no history of stammering or stuttering. There were no other infantile neurotic traits of outstanding character.
She passed fairly well in her studies, went to the third grade in High School by seventeen and went to a business college for a short period. There are no signs of congenital lues, she has never lived in the tropics, suffered any severe accidents, is 5 feet 4/ inches in height and now weighs 130 pounds; her weight was 152 pounds four years previously. She had a general pyknic habitus. She began to menstruate at thirteen and one-half years , and has always been regular in this function. She has smoked since about sixteen to seventeen years of age but never excessively; does not always inhale.
History of illness: In December, 1924, she was in excellent health. She was an outdoor girl, enjoyed golfing, motoring, dancing, was popular, made friendships, had healthy social contacts with young men and was engaged to be married when she was taken ill. She was helping a brother during the Christmas holidays in a retail store and was very busy when one night she awakened out of her sleep "in a sort of chill or spasm" as she expressed it and was afraid she was going to be ill. She was at the home of a cousin, used a hot water bag and in spite of herself felt an uncontrollable urge to talk to her cousin. This she did all night long. She narrated all sorts of incidents that were connected with her work at the store in a feverish, turgid manner, connected, but hypomanic in its intensity. Then she began to notice things upon the wall. It seemed to be alive with little black bugs crawling in every direction. These then seemed to cover everything, including herself, her arms, and her chest. This hypomanic state lasted uninterruptedly for about three days, and she was quite, solicitous of her condition and made frequent complaints that no one was interested in her and no one would pay any atention to her dire distress.
She then saw double and was confined to her bed for about six weeks. During this time everything seemed blurred and confused. She was restless at night but sleepy all during the day time. There were no ascertainable paralyses but she was weak and distressed. She was better by the middle of February and then had a slight relapse. She was always tired and depressed and consulted a local specialist who, according to her story, told her she was "filled with germs" and who started to clean out her gall bladder. This procedure was extremely distressing and after the fourth or fifth treatment she could not stand it any longer and Dr. Loeb was consulted. At this period she was asthenic, emaciated, had a severe leucorrhea, and had attacks of tremor of the entire bodily musculature.
ByJune, 1925, she was able to lie in bed in the sunshine and then the disordered breathing began. At first she had attacks of rapid breathing four to five times a day. The attacks would last four to five minutes only during which she felt that she was unable to get her breath-" her windpipe was closing on her." She had typical anxiety attacks, would rush to the window to get her breath in a veritable attack of air hunger. Her appetite was good, but she could not sleep. Hypnotics were then ordered and were used all summer.
They were chiefIy bromides (Somnos). She saw Dr. Spiller in July and Dr. Ornsteen later. Her nose seemed to be stopped up and she could not breathe through her nose.
The breathing spells then became more and more frequent and by Septenber of 1925 had become almost continuous. She had f requent crying spells, ungovernable yawning and great prostration. The leucorrhea became more and more annoying and she used douches to control the itching which was constant. This leucorrhea had been bothering her off and on for sometime.
Regarding this leucorrhea some notes sent me by Dr. L. in February, 1926, indicated, that this was an old difficulty. Dr. L. writes: "Shortly after Miss Y. had entered a school in Boston (1918) she had some abdominal pains. She had an acute salpingo-oöphoritis on the left side-with appendicular involvement as well. The appendix was removed and part of an affected ovary of the right side. Later she had a curettage and adhesions which had caused a uterine displacement after the original operation were relieved. The microscopical examination of the discharge was reported negative."
Dr. L. gave me a summary of her condition at the time of her acute illness. She had the beginnings of an acute exophthalmic goiter with characteristic circulatory disturbances and small tumor. The exophthalmos was bilateral, l>r, Stellwag and v. Graefe positive. Pupils sluggish, diplopia, and visual fatigue. There was a fine involuntary tremor which increased on excitement. The patient was talkative and resentful and would talk night and day. Insomnia was marked and was controlled by hypnotics. These Dr. L. emphasizes were the most marked signs of her encephalitis attack. She began to lose weight, and then went through a deep lethargic phase in which she could not be aroused and had a pronounced amnesia for all the events of this period.
Dr. L. further noted the following:
Three to four months after her recovery from the acute phase she developed the following sequelae.
(I) True respiratory disorders. Polypnea, bradypnea, apnoea and periodic respiration.
(2) Respiratory pauses.
(3) Dyspnea with vasomotor disturbances.
(4) Inversion of respiratory formula or rhythm.
(5) Sighs and gaping.
(6) Abnormal nasal sensations (occasional marked mucous discharge).
(7) Palpitation and tachycardia are very marked.
(8) Quite recently she has developed some hysterical phenomena.
My own neurological examination of February 8, 1926, briefly narrated showed the following:
Some nasal grimacing related by patient to her difficulty in breathing but no anosmic or hyperosmic difficulties.
Sight O.K. No hemianopsia or fundus changes and no scotomata or restriction of visual fields.
Ocular muscles freely movable, no present diplopia. Pupils equal, slightly sluggish to light, r=l.
Trigeminus, facial, auditory and other than vagus nerves O.K. on general examination. No altered oculocardiac reflex. Sialorrhea is profuse, epecialIy at the end of the yawning attacks.
Upper extremities no pareses, nor anesthesiae, twitching and marked hypertonus and some rigidity. All arm reflexes + + +. No tremors save after some of the respiratory seizures when the patient had a generalized shivering reaction related to cyanosis, but she says she does not feel cold. No taxes, adiadokokinesia, or sensory defect.
Polyuria and polydipsia are both present. Slight stiffness of parkinsonian type. Patient states she feels as though "strapped to a board" when in bed. Is tense all over. No cogwheel phenomena.
Lower extremities as upper. Increased tonus, partial rigidity, increased patellar and ankle jerks + -j-, no clonus, no Babinski, Oppenheim, Gordon or Chaddock signs. No sensory disturbances. No gait disturbances but patient has slight propulsion-mild parkinsonism. No trophic disturbances, dermographia or Sergent line. Irregular tachycardia, variable, but no murmurs and no pulmonary signs. Larynx O.K.
The respiratory disturbance is extreme. It is almost constant. The patient is in extreme exhaustion from her breathing difficulties. She pants for breath as it were.
The attacks are in reality paroxysmal but are so frequent as to seem persistent. As one watches her breathing one is forcibly reminded of a fish gasping for breath. She breathes on the average 35 to 45 times to the minute, the mouth opens, the lower jaw is pulled down, there is a fairly long inspiration and a sharp violent expiration. This goes on for from two to five minutes, then there are several gaps or yawns, and if a long satisfactory yawn is obtained she is over the attack for from two to five to fifteen minutes, but more frequently the yawns are only half satisfying and an apneic phase begins, the lips get bluer and bluer, the chest, and diaphragm (see tracings) are held, the hands have a tendency to clench and she salivates and becomes absorbed in her agonal fixation and after one to two to three minutes commences to gasp again for breath, the color comes back and another gasping respiratory episode is on.
When a deep yawn seems to terminate an attack she can converse and narrate her story or take up any topic brought up. Sometimes these free intervals last five to ten to fifteen minutes. The longest in my office has not been over fifteen minutes although at times she states she has a free interval of an hour.
The breathing attacks cease when she is asleep so far as can be ascertained.
These attacks have been stereotyped now for the three months under observation. I have taken some cinematograph pictures, parts of which are here reproduced. As noted shivering tremors sometimes come on after some of these attacks. Rarely a day goes by without these.
For the first month no restriction was placed upon the use of hypnotics. She continued the use of her hypnotics and begged for something to give her sleep. Her usual sleep was rarely more than two to four hours a day.
The day's program was irregular but was approximately as follows: If she took her hypnotic, she would sleep from 10:30 at night to about 4 in the morning; then the breathing difficulties would begin. She would stay in bed until noon or 2 or 4-get up for a few hours, with slight sleeps in-between and again retire after supper.
Wishing to try out some pharmacological agents I gave her at various intervals, luminal, veronal, tr. hyoscyamus, scopolamine, hyoscine, tr. belladonna. The results were of great theoretical interest but were not of any therapeutic value. At one time a mixture of R. Veronal gm. .02, Tr. Hyoscyamus .01 q. 3 hrs. led to such a profound regression that the patient went almost into a drunken coma after three days medication. She could hardly be aroused and as she expressed it " felt heavenly." She clamored for more. I pushed it a trifle until the patient herself felt a little alarmed. Tr. Belladonna which A. J. Hall speaks of as being of service, was of no use and scopolamine was worthless.
After three weeks of the drugs she consented to give up all drugs as she realized in a sense what she was after-speaking in terms of "Nirvana "-or the "return to the womb" in psychoanalytic terms, and she realized the significance of her regressive wish but stated "she was so tired," she welcomed death.
In April, through the courtesy of Professor Twitmyer of the University of Philadelphia I obtained some pneumographic tracings and append his interesting report and parts of the pneumographic tracing.
The subject was placed in the apparatus at 2 :34. p.m. The pneumograph was applied to median frontal body o line of nipples. The lower tambour was placed directly beneath it, the center of the bag about two inches above navel. At that time the subject was undergoing an episode of breathing attacks as evidenced by breathing curves at point "1," and continuing to point marked "2," at which time it was our opinion that perhaps we were getting the action of the lower intercostal muscles rather than diaphragmatic excursion, so the lower pneumograph was placed on the subject about four to six inches below the navel. Immediately there becomes evident a change in the form of the curve, the establishment of a higher base line probably to be interpreted as due to an involvement of breathing which causes the release of some of the residual air.
At points "3" to "4" a pulse reading was made on the girl and found to be 110, respiration 34 per minute and at the point marked "5" the subject was seated since she objected that she was feeling quite fatigued and the strain of the test was telling on her.
At point marked "6" was the first time that the girl showed any signs of calm and there was a slight cessation of terrific breathing occurring at points " 7," " 8 " and " 9."
At point ' 10" was the first time that we were able to get her quiet and this state we produced by supplying her with a book from which she read silently. Records show that there was a complete apnea, the cessation of breathing showing itslf in almost a straight line for both diaphragmatic and intercostal muscles.
At point marked "11," the girl having reached complete exhaustion gasped several times quite audibly.
At point "12," she again resumed an apneic state, compensatory replenishment of breathing in evidence at points " 13," " 14," " 15," "16," etc.
The record was completed at 3:10. The marks at the bottom of the record are the metric swings, the markings being at the rate of 60 per minute.
While my contacts with post-encephalitics has been somewhat restricted nevertheless Miss Y presents an unusual picture inasmuch as her breathing episodes are not accompanied by any mental departures. It has been my experience with previous cases that breathing spells or other mental disturbances seem to run pari passu with the respiratory disturbance. However, in her case throughout our examination she maintained a very pleasant and docile attitude. Her sense of humor, her mental alertness and her general behavior are not affected despite the fact that the physiological malfunctioning of the breathing mechanism becomes excessive. At one time she asked us to release the belt about her waist, that it was causing considerable annoyance and preventing her from breathing. Then she said that she would be most happy if she could yawn and relieve herself of the fatigue.
At several times after we had begun our work and when the curves were running quite high she was markedly cyanotic and once or twice rolled her eyes back; eyelids drooping, a spell definitely epileptoid in character. At no time was her conversation incoherent or were there any other evidences of aberration or hallucination or other abnormality, and no period of unconsciousness unless the transient epileptoid attacks to which we refer are moments of unconsciousness comparable to petit mal. In order to afford a temporary respite from the breathing disturbances I asked her to attempt to vocalize, utilizing some vowel sounds as a medium through which to discharge the breath. This exercise is similar to ones which I employ in orthogenic speech work. This afforded her considerable relief, controlled the breath and momentarily synchronized the movement of intercostal and diaphragmatic musculature.
Baron Constantin von Economo1876 - 1931

Sleep as a problem of localisation von Economo 1930 - pdf

parkinson encephalite