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The history of neurosciences at La Pitié and La Salpêtrière J Poirier 

mise à jour du
28 octobre 2007
Nervous and mental disease monograph series N°45
New York and Washington
Nervous and mental disease publishing company
Postencephalitic respiratory disorders
Review of syndromy, case reports, physiopathology, psychopathology and therapy
Smith Ely Jelliffe
27/10/1866 - 25/09/1945


Part III page 73-100
Case report II page 63-72
A complete analysis of the phenomenology of this disordered type of respiratory behavior will not be attempted here. Such would involve physico-chemical, physiological and psychical considerations, utilizing the level hypothesis originally suggested by Y. Baer in his recapitulation theory, favored by Hughlings Jackson, more completely elaborated by Y. Monakow and followed by Jelliffe and White in their Diseases of the Nervous System (see Introduction, Fourth Edit., 1923).
Physico-chemical studies along these lines are certainly as yet quite incomplete, important though they may be, especially for the understanding of a number of metabolic ph enomena observed in these encephalitis cases. The knowledge of the highly intricate correlations of vegetative neurology ànd metabolism variations are but in their beginnihgs in the study of the Biology of the Individual.
We here contemplate but a brief review of certain pathophysiological situations and a tentative çntrance into the psychical coördinates in the effort to bring a possible monistic attitude to bear upon the comprehension of the picture of the respiratory behavior.
Inasmuch as the mode of approach is dynamic rather than iosological such terms as hysterical, degenerate, dementia, psychopathic, etc., are of no particular significance here.
In previous pages, I have tried to give a résumé of the chief available studies. I do not claim to have found them all, but those quoted are the essential ones. Some of these are of special value or our problem in that the respiratory movements have been observed in greater or lesser detail and graphically represented by the methods at present in vogue. They are naturally very uneven in their detail.
The earlier studies concerned themselves with the acute respiratory yndromes. These are here put aside for the consideration of the esidual or chronic forms with which this study deals. These acute manifestations are not to be neglected by any means as many pathological studies show that death has resulted from involvement of the essential respiratory neural mechanisms (Goldflam et al.), and hence, inferentially, in the residual respiratory disorders which are strictly homologizable with the acute respiratory syndromes, some impingement upon these complicated mechanisms must be admitted as playing a part in the residual types under specific consideration.
Furthermore it is believed that the muscular anomalies of respiration are in many ways to be coordinated with other muscular anomalies of the larger encephalitic syndrome. Achard (p. 57) has drawn attention to the similarities of myoclonic diaphragmatic breathing to other myoclonias. Similarly Cheyne-Stokes breathing with its usually lethal outcome and Mendicini's interesting initial pneumographic study of breathing anomalies in the acute stages show striking similarities in the residual syndromes. thus Reys 1 in his interesting study has called attention to the myoclonic expiratory form as a residual in a succinct manner paralleled in our Case II.
Turner and Critchley, to first take up the most recent of the studies in the respiratory phenomena have followed G. Lévy's classification with slight modifications. Thus:
(1) Disorders of Respiratory Rate (Tachypnea and bradypnea). In Lévy grouping. (1) Respiratory Disorders proper. Alterations of rhythm-polypnea chiefly (tachypnea is preferred by T. & C.) bradypnea, apnea, accessory periodic respiration.
(2) Dysrhythmias or disorders of Respiratory Rhythm (CheyneStokes breath holding spells, sighs, forced or noisy expiration, inversion of the inspiration-expiration ratio).
(3) Respiratory Tics (Yawning, hiccough, spasmodic cough, sniffing).
Any combination of the above types may co-exist with or without the other sequels of encephalitis (T. & C.). To this we agree save that we have yet to observe a single case of pure respiratory disturbance which does not show some one or more of the now accredited to be "encephalitis" signs. Should we find such a respiratory syndromy absolutely ure we would not necessarily exclude an "encephalitic" causal. factor but would be inclined to hunt psychoanalytically for 4 characteristic psychogenic goal and hence ally such a casé withthe purer (psychogenic) types.
Bériel's study, elaborated in Hardoin's early thesis (1921) affords is, historically, with the first intimation of explanation of the altered breathing, hence we will discuss micropnea before polypnea. After illustrating respiratory tics, they speak of a special form of micro pnea in parkinsonian cases in which the respirations are rapid and superficial the diaphragm alone being in activity. There is no paralysis and Hardoin says neither central nor peripheral neural processes are involved. The essential feature is the thoracic rigidity which is allied by them with parkinsonian rigidity. Furthermore the tic-like brusque movements Hardoin correlates with a diaphragmatic myoclonic spasm or an accident of compensation arising in the course of the micropnea. These are related by him to some somatic disturbance. Gamble, Pepper and Muller's interesting experiment, already cited, make this improbable. Suckow's interesting paper further illustrates this micropnea in alternation with tachypnea, apnea, and with yawning episodes.
Bulbar involvements are not probable; paralyses of the intercostals, diaphragm, pneumogastric are equally to be excluded. Superior centers. of, coordination such as lie in the corpora striata may possibly be involved but the author passes this by lightly and formulates the hypothesis already mentioned that of thoracic rigidity of a nature allied to parkinsonian rigidity. Radioscopic study showed complete immobilization of the base of the thorax. Thus as Bériel has pointed out other micromotor syndromies find their analogues in this micropnea, micrographia, minimal movements of the jaws, and other associated micromuscular activities. (Compare Suckow's studies.)
The acceleration according to Bériel is a compensatory process founded upon oxygen need and therefore the diaphragmatic exaggerations are in liaison with the thoracic fixation. Bulbar implications are not of help in the explanations, but Hardoin admits that higher coordinates-corpora striata-may be implicated.
Bériel and Hardoin's point of view has partial validity for certain of these cases and is concurred in. It is certainly a part of the present task to learn if possible more of the complex mechanism of respiration not only in its purely oxidative function but also as to the relations of chest and diaphragmatic movement as carriers for higher symbolic equivalents with which we are fairly well acquainted in their speech mechanism activities.
Laignel-Lavastine and his assistants have also demonstrated an asynergia in the automatic respiratory movements with a dissociation between the right and left halves of the diaphragm.
Tachypnea. Turner and Critchley discard Lévy's much used term polypnea entirely although they follow her general descriptive outline.
Tachypnea (T. & C.), polypnea or tachypnea (L.) is the commonest of the respiratory anomalies-(the most important-L.-). It may be permanent or paroxysmal, during sleep or only during the waking hours. We have observed both but in cases I and II here outlined it was, present only during the waking hours-save in a few instances of half.sleep when it was continuous in both the cases here reported.
Turner and Critchley state there may be no cyanosis-in both of the cases reported by us here there were apneic periods with cyanosis and most of the case histories here given in abstract report the occurrence of an apneic phase with trance-like states or semiunconscious phases. Turner and Critchley speak of the patients usually suffering no inconvenience. Such has not been our experience in the numerous cases we have seen in various countries and in various clinics, where nearly all have complained of great inconvenience and of intense effort trying to get their breath. .
The fixation of the chest as observed by Bériel and Hardoin obtains according to Turner and Critchley in the parkinsonian cases. only. Such also has been our experience. It is notable in our Case II.
Paroxysmal (polypnea) tachypnea according to Lévy is the most frequent type, this has been our experience and the historical résumé bears this out. Lévy lays stress upon the "towards evening" occurrence of these attacks and Turner and Critchley speak of it also, when the attacks may last from a few minutes to several hours. In the cases here abstracted no determiners were really intelligently sought for Lévy states that this evening oncoming situation was particularly true for children and often lasted all night. Our own experience has not dealt with children save that the psychical reduction universally present makes all of these patients children. That certain symbolic determiners are present is our belief; of this later.
The breathing attacks according to most observers are under some sort of voluntary control. Emotional stimuli are of much moment in inducing or modifying them. Turner and Critchley state that eating may stop them (see Hardoin curve for deglutition). In our cases I and II eating time was a particularly efficient stimulus in inducing them. Paroxysmal or permanent tachypnea seem to be quantitative grades in our experience. As the patients recover, for reasons as yet inexplicable (save for those here advanced as for some recoveries) the permanent types tend to give way to paroxysmal types, and such a course argues for beginning partial or complete recovery. Turner and Critchley call attention to Buzzard's observation concerning the dissociation of many complicated activities in encephalitis during which purely automatic activities such as swallowing, speaking, breathing, etc., seem to be split and only become possible under directed voluntary activity. This feature of functional dissociation is of much significance from the genetic point of view of behavior to be here developed more in extenso.
Attention has been called to the tetaniform complications of the hyperventilation of the lungs in the paroxysmal and permanent tachypneas. The observations are old although Barker and Sprunt would speak of their findings as new. These have been dealt with in the opening paragraphs of this résumé and inasmuch as it bears specifically upon the chemical problems involved cannot be entered into here even though we are inclined to feel that far reaching situations are involved. Adlersberg and Porges have offered an introductory chapter into this and it must be left here.
Our case II offered an exquisite example of what has been described as a persistent tachypnea-yet here it was evident that periodicity was present. Our reading of the many cases tends to make us believe there is no really permanent tachypnea. Even in the cases cited by Lévy and in her pneumographic traces there is evidence of a certain periodicity. There is a rise and fall, and attacks can be separated even though the interval seems slight at times. Suckow's tracings show some very striking alternate apneic and tachypneic attacks.
In our case II which is one of the most severe we have seen there would be 5-, 10-, 15-minute intervals between attacks-apparently related to diversion or other incidents. Here chiefly the attack would terminate with one or more deep yawns which were accompanied by a feeling of deep satisfaction. Failing such satisfaction the breathing would go on. With a satisfactory deep yawn after several smaller ones-the patient would either enter an apneic phase with increasing cyanosis or be free for a while-(the psychoanalytic correlation with an orgasm (sialorrheal or leucorrheal discharge) was quite evident in this case and will be discussed later).
Lévy -groups these sighing, yawning episodes with the tachypneas: Turner and Critchley speak of them as belonging in their second group. To us they belong with the whole unconscious mechanism and are of special significance when one views the whole situation teleologically. As no one but ourselves, Witzel and Runge have dealt with this phase of the pathopsychophysiological situation we reserve our discussion of these until later and will here indicate the descriptive phases only.
Turner and Critchley speak of these sighs as extremely frequent. Suckow has dwelt upon them at length. Most observers describe them as occurring in normal breathing followed by a short period of compensatory expiratory apnea. This apneic situation is to us of great psychological significance especially when considered from the psychoanalytic viewpoint of early libido distribution between breathing and sucking in the infant. Turner and Critchley speak of them as occurring only during sleep or following slight exertion. This is not our experience.
Tic-like grimaces (T. & C.) spasms (L.) are noted. " Shivers" were present in bothof our cases-and homologized to the involuntary "shudders" often experienced when the bladder is emptied, etc. (orgasmic analogues-envisaged by us).
Apneic phases: are well described by Turner and Critchley and by Lévy, Bilancioni and Fumarola and were marked in our patients.
With our cases they, are clearly homologized with "unconscious" situations of rapt attention-" trance" (B. & F.) and our analysis shows their homology with enraptured and trance states as seen in narcoleptic, hypnoleptic, cataleptic, pyknoleptic, epileptic situations. Here are a series of dissociated phenomena of great interest and complexity which run back to infantile fixations of rapt interest in which artistic intuition of the significance of the "Transfiguration "-" Danae "-" Leda and the Swan" not to mention many variants from the upper reaches of spiritual transport to the lower grades of erotic behavior are to be evaluated.
It is not to be inferred that such trance-like states are necessarily so correlated. In common, sense terms "evry tub stands on its own bottom" and hence only detailed study of the individual patient can determine the exact situation. Our own attention has been directed to such individual teleologies and of these we shall speak later.
Irregular respiration, bigeminal and trigeminal, dissociated costal, thoracic, nasal, or laryngeal types are frequently met with. It is probable that these modifications each in turn have their special significance. Van Bogaert has studied these minor variations here in detail and speaks of alternating types as well as bigeminal and trigeminal typs. Our, own experience shows that all of these types are present but rarely in any stereotyped form. The gradual running down of a breathing attack is often very striking. Van Bogaert has charted some of these and shows that bigeminal and trigeminal breathing often issues in the apneic phase of an attack. Our cases frequently showed this. Van Bogaert speaks of changes in the tachypnea occurring from changes in position.
The personality make-up is probably of considerable significance. There is little available evidence upon this point but students of speech, of singing, etc., are well acquainted with such variations as pertaining to such backgrounds. Bilancioni and Fumarola's important contribution discusses these laryngeal and related features extensively.
In our case II for instance the prolonged expiratory phase corresponds with other breathing situations. She always had a tendency to discharge her speech explosively, and this feature is quite pronounced when she would smoke a cigarette. Whereas in many individual smokers, inhalation is most pleasurable, with her strong exhalation was the preferred type of activity.
As one studies the many pneumographic tracings on record these irregular types are plainly in evidence, at times in almost all cases, even though a predominant breathing pattern tends to be followed in each individual. Bilancioni and Fumarola's tracings are especially interesting from this angle. Two of them are here reproduced.
Turner and Critchley emphasize breath-holding episodes. They here refer to those who hold the breath in deep inspiration. "These paroxysms are ushered in by a series of deep, forced inspiratory efforts with noisy expirations: the patients feel dizzy," or as if there were something in the chest interfering with full inspiration. A very deep inspiration is then taken and maintained for a period of ten, twenty or thirty seconds. Choreo-athetoid movements, grimaces or bizarre movements may accompany these. Sometimes consciousness is cloudy during such as in their cases 1 and 5 and our case I.
Our own cases showed a partial reversal of this formula. The patients simply stopped breathing. Case I would go into a trance sometimes lasting a long time, 5 minutes with cyanosis, cold extremities, tetaniform cramps in hands and feet and as recorded a few almost epileptiform states. Case II would stop breathing, become cyanotic after a few great yawns, then after 5 to 30 seconds start on her labored breathing. If the yawn was "satisfactory" the apneic phase might be omitted and she would talk for from 5 to 15 minutes, sometimes even longer, and then another paroxysm would supervene. With her there was some subtle interrelation between something obtained by the yawn and by the apnea. The better the yawn, the less the apnea. Shivering attacks sometimes would follow an apnea, but rarely occurred when there was a good yawn.
A somewhat similar series of displacements was also seen in case I. The wish to micturate and these shivering attacks were in some way correlated as well. Lévy (p. 145) has called attention to involuntary micturition in one of her cases associated with spasmodic cough. Case I of our series would go to the toilet after a severe breathing spell. Wimmer's case 12 (p. 73) had nocturnal enuresis for many years previously.
The behavior of other patients during these breathing spells deserves a special chapter and cannot be here detailed. Only Runge's case will be cited in that the attempt to strangle himself should be brought into relief as possibly throwing some light upon the apneic situation. As apnea might be thought of as a special mode of strangling (self-destruction wish), Runge's theological student with his "ideas of sin "-also present in our case II in a modified manner -is thought of as deserving special comment and possibly to be related to the psychopathology of certain of these cases.
The Roch-Schmidt case who tried to hide, and others who banged themselves on the floor might also be brought alongside of the regressive suicidal wish-phantasy situation. Runge's case is deserving of more extended study here and also Hauptmann's extensive autobiographic case.
A final word may be said concerning the minor respiratory phenomena classed by Lévy, Turner and Critchley and others as tics. Bignami as early as 1920 drew attention to these and allied them with the Dubini's electric choreas.
Zingerle and others, as already noted, have allied them with diaphragmatic myoclonias. Since this enters into the large group of hiccough cases (see Wimmer,) with Turner and Critchley we leave them with a mentioh only save noting the interesting myoclonic diaphragmatic tic case of Gamble, Pepper and Muller.
Other nose sniffling and mouth blowing tics are also omitted full mention here. Lévy, Francioni, Parker, Babinski and Charpentier and others note them. The nose sniffling attacks were very pronounced in our case I and led to a nasal operation.
Wimmer has dealt with them, quite clearly; He speaks of constant sniffling, hawking and spitting; Noisy puffing and hissing or snorting through the nose or mouth, paroxysmal or phasic. Serial yawning or sighing, sighing and hiccoughing. Wimmer's case 12 had as already noted pronounced yawning attacks, antecedent to a tachypnea. She had jerky fits as many as 20 a daylater 135 and her tachynea would rise to 70 noisy respirations, to the minute. This case is further of interest in that it was preceded by hiccoughing attacks a year previously.
Isolated yawning attacks have also been recorded by many observers. Our case II is a classical example (see Figs.) also Turner and Critchley's case 2 and cases by Abrahamson, Buzzard, Howell, Pardee, Mayer and Saussure, Sicard and Paraf, Wimmer and others.
Whoping cough like attacks were studied by Marie and Lévy and others and are noted as introductory to later respiratory difficulties by many, authors-see case I. of Turner and Critchley.
It is often stated that these tics may occur as isolated but closer study nearly always reveals other respiratory situations. Many observers fail to mention any of these tics. As Turner and Critchley note possibly they were not looked for.
Bilancioni and Fumarola, Lévy and many others refer to the "hysterical" "pithiatic" hysteriform (Wimmer) nature of these phenomena and Lévy devotes some pages arguing as to their "organic" nature. Most authors seem steeped in the parallelistic or dualistic doctrines of old time neurology. Inasmuch as this type of presentation does not appeal to us, since here the psyche is deemed as old as the soma and one, the discussion of the pathogeny problem involved is here touched upon to be discussed more in detail later.
smith ely jelliffe
In view of the great diversity of the phenomena already envisaged as respiratory it is illusory to hope for any monistic interpretation as to pathogeny This situation has been emphasized for the larger encephalitic syndromy. It is equally true that even the respiratory phenomena are complex, in spite of the limitation of the field of observation. The statement of Turner and Critchley that "at the present time the discussion as to the causation of the postencephalitic respiratory disorders becomes purely speculative" can be better expressed by saying that, certain of the phenomena can definitely be run down to definite lesions-notably the Cheyne-Stokes breathing, so often seen in acute situations and persisting at times partly modified into the later stages-whereas at an opposite pole definite psychogenic factors can be seen to be operative as the results of diaschitic splitting or dissolution of function due to partial involvement of higher cortical reflex pathways. Until more is known of cortical pathoclisis the structural correlates here will remain unknowth. Pathogenic interpretative formulae for intermediary situations, possibly seen statistically as preponderating, remain as Turner and Critchley well state, undetermined, by reason of a multiplicity of factors, hence speculative.
A historical review of the general situation brings out the complications surrounding any monistic interpretation. Turner and Critchley deal with four of these as follows:
(1) Peripheral origin hypotheses. Bériel, Hardoin, Vincent and Bernard, Laignel-Lavastine (diaphragmatic dissociation), and others.
(2) Various thalamic hypotheses. Here the afferent stimulus is thought to be blocked and thus the phenomena are brought in line with the thalamic sleep hypotheses. (Jelliffe et al. for sleep.) Pardee as a suggestion merely for the respiratory phenomena described by him.
(3) Bulbar localizations. Definitely shown in severe involvements, Goldflam et al-for specific types-Cheyne-Stokes, etc., and assumed for attenuated forms Roch, Rosenow and others.
(4) Turner and Critchley advance the situation a bit and include higher psychomotor tract involvements which will be here discussed as relevant to the general dissolution of function aspects since respiratory function as such is known to have voluntary cortical regulatory mechanisms.
(5) Furthermore the larger mechanism of respiratory expression -emoting functions, which are of so much importance in the higher psychical activities of speech behavior should be included-and
(6) Still further attention should be directed to those coordinating pathways which sweep up visceral components into the thalamus, striatum and cortex for the body as a whole in its emotive synthesis.
Diaschisis here while as yet unanalyzable to our complete satisfaction may be reached for when the entire respiratory syndromy is reviewed as an aggregate.
(7) Finally it seems not inopportune at this juncture to bring into the discussion certain metapsychologic& points of view which the conceptions of the Super Ego, the Ego, and the It as formulated by Freud and the psychoanalytic school in their studies of the traumatic neuroses, the conversion phenomena, substitution phenomena, organic psychoses and organic disease itself.
It is probable that in this or that individual that one or all of these factors can be brought into relief and contribute some light to this highly complex series of phenomena.
It is a commonplace in the casuistic material to find organic involvements of liver, intestines, skin, kidneys, appendix, pancreas (diabetes), hypophysis (obesity), etc. These visceral implications must have their reverberations in the central organs of the Ego, metapsychologically considered, just as in a gross metaphorical sense, the captain of a ship knows where something is wrong with his machinery or his crew working the same. Psychotic splitting is so frequent as to raise the issue, why? and what is its function? Repetition compulsive phenomena (sterotypies, palilalia, etc., etc.) are equally prominent. The entire literature is shot through with the lazy and inadequate summary of "hysteria," i.e., conversion phenomena, as viewed psychoanalytically, and the hospitals are filled with patients whose behavior resembles that of the picture of the traumatic neuroses, in some of which the respiratory phenomena, particularly at certain periods, show the characteristic anxiety neurosis phenomena of the Freudian formulations.
Whereas it is recognized that this "classificatory" partitioning of the material is but a logical artefact yet the scientific method as such is reduced to the utilization of such fictions in order that analysis and synthesis can be brought about for pragmatic purposes in the handling of individual cases. I need not unnecessarily dwell upon this old Protagorean-Socratic series of antitheses between particulars and universals which has been the battling ground of the philosophers from time immemorial.
(1) Peripheral (Muscular) Origin Hypotheses (Fictions).
These are not "theories " as others have termed them. It is doubtful, following Vaihinger, whether they have even the validity, of hypotheses, but it will serve little purpose at this place to split logical hairs of scientific method.
As already indicated Bériel and his pupil Hardoin, in his thesis -elaborated the notion that the tachypnea was a compensatory phenomenon to make up for the micropnea which was conditioned by a striatal rigidity affecting the intercostal muscles. As Turner and Critchley correctly observe this cannot be true for all the cases since in a number no such parkinsonian rigidity exists in the muscles.
Our own observations-in addition the two cases here reported as paradigmata-tend to show that the Bériel-Hardoin observations have considerable validity. Most of the cases seen by, us have had a certain grade of this "rigidity "-i.e. static tonus, but it is here regarded that this increased breathing is not a reflex phenomenon solely conditioned by the hypertonus, but rather the view is held that both the breathing and the tonus have a more unitary conditioning. Thus the hypothesis is not a peripheral one but is more complicated and thalamic and striatal pathogeny are involved. What this may be will be discussed under the general heading of an ego defense mechanism (postural attitude) which takes into consideration a number of inimical organic offenses, from other organs than the respiratory ones alone.
Turner and Critchley include here the diaphragmatic myoclonic movements-really referable to the "tic" types. These myoclonic situations-epidemic hiccough, Dubini's electric diaphragmic choreas, etc., while manifestly of muscular origin do not properly belong here. Gamble, Pepper and Muller's phrenic freezing experiment seems to show that the synapses of this nerve are involved in the reflex chain in these myoclonic diaphragmatic tics.
(2) Thalamic Hypotheses.
Our own observations tend to show that thalamic involvements are very frequent and register themselves early in the lethargic features of the general encephalitic syndromy. (Certain pharmacological agents, particularly of the alcoholic series-chloral, veronal, trional, medinal, have induced deep sleep and a marked cessation of .the respiratory disturbances. Just what deductions are to be drawn from these still remain for further study, especially in view of what Schilder writes in his Lehrbuch der Hypnose about medinal poisoning experiments and changes in the central grey of the III ventricle which has vegetative functions, maybe re sleep as y. Economs hypotheticates.) Direct associations between the respiratory situations and the thalamic implications are undoubtedly present in many cases. Careful consideration of the Dejerine-Roussy, Head-Holmes, studies upon thalamic-cortical interrelationships relative to the handling of the afferent impulses from implicated extero and interoreceptors leave a number of thorny problems to be more carefully studied.
It seems still open whether the thalamic hypothesis is a main situation as now conceived. It must be left for a special study of how these patients handle the specific incitors of their attacks. Thus in case I certain suggestions have been advanced relative to specific incitor factors as operating to induce or to control the discharge which has been flarrowed down to the respiratory apparatusoperating at low ontogenetic levels.
When it is firmly held in mind that all movement, whether automatic or voluntary, implies response to stimuli, external or internal, either conscious or unconscious, the possibilities of handling by the thalamus or by that of its sensory homologues at the same level are not too easily dismissed. As one reads the earlier studies of Gerstmann and Schilder, then those of Förster, of Böstroem, Wartenburg, Cruchet, Wilson, Gamper and Untersteiner and many others, it has become more and more evident that certain definite behavioristic patterns appear either in pure culture, as it were, or mixed with other patterns. At times these patterns have been isolated-Wartenburg's studies upon athetosis and upon torticollis may be cited among others -while particularly noteworthy are the observations of Gerstmann and Schilder and their confreres, the study of Böstroem and the most neatly analyzed case by Gamper and Untersteiner. Here was a complex group of movements which, briefly indicated, started with a mouth opening, turning of the head towards one side and a series of compensatory torsions to meet the original mouth stimulus. The authors analyze it on the basis of a yawning reaction and then pursue it further as a reflex response to an oral stimulus such as occurs in nursing. They show that the whole movement is but an extensive spreading from this original sucking stimulus. They offer no introspective material upon this point, as is believed necessary from the viewpoint maintained here, but the purely behavioristic analysis is so strongly confirmatory Of the point of view here advocated-i.e. the dissolution of function to earlier levels of behavior.
Here it is evident that the initial sensation starting in the mouth undoubtedly reaches the thalamus, and from here on-as with the Head and Holmes series, an exaggerated an1 diaschitic response is released in the form of an isolated pattern. It seems highly probable then that careful histopathological scrutiny of the thalamus and its homologues will be fruitful. This has already begun but cannot be discussed further here since it is all too general.
Tilney and Casamajor have attempted the analysis of the isolation of these bits of patterned muscular response (automatic associated control) in lower animals by the myelogenetic method and their work is here conceived of as of great importance in the field now under revision
(3) Meduliary and Higher Localizations.
It is not at all surprising in view of the many cases of respiratory death with definite lesions microscopically observable (Goldflam et al.) that most observers have looked upon the respiratory difficulties in the postencephalitic as attenuated types of such medullary-bulbar implication. Here two conflicting series of observations stand out. In the one the respiratory difficulties have been developed directly out of or were continuations of the early stages of the respiratory phenomena. Should one reread the many observations here recorded it will be seen these were in the minority. On the other hand the post-encephalitic respiratory difficulties have supervened many months after the initial difficulties. In many, it is true, that the interregnum has shown many sniffling, hawking, coughing "bridgs," yet the purer types of tachypnea, regular or irregular have seemed to become consolidated often many months after the original difficulty. It is of interest to note that Wimmer in his very masterly study follows v. Economo and thers and has repeatedly called attention to reinfection or persistence of subinfection to account for the advance in the symptomatology of these post-encephalitic cases. While we believe there is no definite proof to show that this is not so and possibly none in its positive favor, the point of view here outlined is that this conception must be set alongside of or possibly in opposition to the view that regression of function through focal disease elsewhere is of significance, and furthermore the whole problem of dynamics is opened up. We mean by this that minimal focal disorder may raise a threshold so that the energy flow, by regression, psychologically considered, may take other pathways for its discharge. In a sense analogous to the use of a single switch line when others are blocked.
Degradation of function through relative disuse is seen everywhere in human pathology and it will be one of the features of this review to accent this well known principle especially as it calls for a larger therapeutic ingenuity than the more or less fatalistic attitude of "progression of a disease process through reinfection."
Personal observations have shown repeatedly very marked functional regression in the respiratory syndromy especially during some intercurrent disturbance. Thus case II is markedly worse during a menstrual epoch and also during a tonsillitis. Note has been made of the breaking out of the respiratory syndrome following a tonsillectomy in case I, and I have gathered a number of observations showing marked regressive behavior disturbances of the schizoid type in postencephalitics also following tonsillectomy. Hardly can it be argued seriously that a tonsillectomy can constitute an advance of, the infection or a reinfection but it can be legitimately considered as a factor making for regression.
To cite but two bits of evidence from many bearing upon the increased susceptibility of these patients. One study of Appelroth is of interest. This investigator has shown a marked increase of stimulus reaction on the part of the skin of the postencephalitic to X-rays, while an interesting study by Beringer demonstrates that muscular strain may bring about a distinct advance in the postencephalitic syndromy. These lines cannot be followed further here although they merit specific consideration.
Such regressive activities are widely observable not only following external stimulus such as the light stimulus in Appelroth's case, or the fatigue brought out by excessive exercise, or following an infection or a toxemia. They are observable in the postencephalitic behavior disorders, respiratory as well as other types of behavior, from the slightest and subtlest of purely psychogenic stimuli.
It is a commonplace of modern day, even of ancient time psychiatry, that the sick individual was more than keenly alive to his surroundings. In present day terms the uncannily wise unconscious has come through the resistance of the repressing superego mental system and comes into direct intuitive contact with the surroundings.
Like the so-called sensitive "medium" they "divine" inimical forces about them. As the lower animal that feels the intonation quality of the master's voice, so, not only the psychotic but the postencephalitic, is keenly alive to the most silent of influences. The slightest frown of a parent is enough to raise the devil in the behavioristic response. It does so with the respiration as well.
This whole problem of the relationships between the psychical and vegetative processes cannot be entered into here, but the encephalitic syndromy has forced it into great prominence, at the same time offering much of importance in the analysis of the complicated processes involved. One aspect of this is taken up later.
To return to the medullary and higher localization hypotheses one can turn to Turner and Critchley's excellent résumé, as well as Wilson's study unless a complete review of the entire respiratory mechanism is attempted. This would require a monograph and more knowledge than I could ever hope to acquire.
The earlier students, says Turner and Critchley, following Wilson, place this respiratory center at various locations in the central nervous system.
A rapid glance at the cinematograph reproductions of the respiratory behavior in case II will emphasize the participation of the facial musculature. Hence Wilson's discussion of this aspect of respiratory behavior may be quoted in extenso since it falls in line so neatly with the underlying thesis of this presentation. Wilson writes:
"The physiological association of facial and respiratory musculatures in the expression of emotion scarcely calls for any comment, so obvious is it. Bell called the seventh the ' facial nerve of respiration'; when the lower face (mouth and nose) is paralyzed it was described by him as 'paralysis of the respiratory functions of the facial.' The implication of the face in sneezing, the facial spasms occurring with respiratory 'gasps' in extremis, the collaboration of the facial apparatus with the other in ordinary breathing and speaking are simple instances of the action of this important synkinesis. The seventh nerve is united functionally with the tenth, and also on occasion with the eleventh and certain upper cervical spinal groups. For simplicity's sake, we may allude to it as the faciorespiratory mechanism. We note that its normal activities are involuntary, i.e., it is under voluntary control only to a limited extent.
"The localization of the 'noeud' of this mechanism is still nocertain; . we have to postulate a center linking the seventh nucleus in the pons with the motor nucleus of the tenth (nucleus ambiguus) in the medulla and the phrenic nuclei (see Gamble study already alluded to) in the upper cervical cord, etc. By all analogies this 'center' must be supranuclear; for the sake of, argument we may suppose it has an upper pontine site.
"Our second preliminary consideration is to bear in mind the existence and function of the respirajory centers proper for ordinary automatic breathing, situated in the medulla. With normal action must also be associated cooperation on the part of the larynx and the face, otherwise normal breathing might partake of the noisy character observed in various diseased conditions.
"The most recent work on the localization of the respiratory centers is that of Lumsden, who has shown, by numerous experiments on cats, rabbits, dogs and monkeys, the somewhat elaborate nature of the arrangements. Thus, he has demonstrated that ordinary rhythmical respiration-quiet, unconscious breathing-depends on several factors. There is (a) an inspiratory mechanism at the level of the striae acousticae; this he calls the 'apneustic center' because when this group of nerve cells is cut off from above, prolonged tonic contraction of the inspiratory muscles ensues ('apneusis'). The level of the striae acousticae is upper medullary. (b) Just below this there is a separate expiratory center (medullary), the existence of which has long been suspected and is now apparently established. (c) Both (a) and (b) are controlled by a higher center in the upper half of the pons, styled by Lumsden the 'pneumotaxic' center, because it regulated normal quiet breathing. When it is cut off from (a) by appropriate section, respiration takes the form of a series of prolonged inspirations, each followed by two or three relatively quick respirations of abnormal type. Lumsden has shown that this cycle repeats itself with great regularity. Evidently then, the pneumotaxic center produces normal respiration by inhibiting the activity of the apneustic center below (behind) it. (d) A fourth, 'gasping' center, situated below (b) at the level of the apex of the calamus scriptorius, is regarded by Lumsden as a 'relic,' and need not further concern us. (But it does concern the postencephalitic who works with 'relics,' through regression of function to lower levels.)
"Our next consideration bears on the influence of voluntary action on the respiratory center in the pontomedullary apparatus. Its automatic activity is set aside voluntarily when we deliberately hold our breath, or when we voluntarily pant, cough, yawn, sigh, take deep breaths, etc. Further, its activity is set aside involuntarily when we are convulsed with laughter, or when we give way to crying, sobbing, howling. Both in the former and the latter case facial movement is involved; we innervate the facial musculature voluntarily for the purposes specified, and the face takes its share in the involuntary expression of joy or sorrow.
"Thus we get the idea of a double control over the faciorespiratory synkinesis: (a) a voluntary control when we choose to inhibit automatic movement, and (b) an involuntary control when that automatic movement is forced to give way to the expression of emotion.
"(1) Voluntary Control. The path followed by volitional impulses to facial and respiratory muscles is undoubtedly the familiar corticopontine, corticobulbar, and corticospinal tract. In particular, the geniculate bundle of the pyramidal tract, from the operculum and lower end of the precentral gyrus, via the genu of the internal capsule, conveys these impulses to the appropriate nuclei. As we have seen, voluntary breathing sets aside ordinary breathing, hence we must postulate, on the principle of reciprocal innervation, a synchronous inhibition of the automatic pontobulbar center. The anatomical course taken by the latter, inhibitory, impulses is less certain, but of their reality there can be no question. It will be remembered that Hughlings Jackson explained the interesting observation he made on respiratory movement in hemiplegia by the existence of double sets of respiratory fibers passing from the brain in this way.
"Lesions, therefore, of the geniculate bundle anywhere in its course especially if they are bilateral-will impair volitional control over the musculatures concerned in the expression of emotion, with the result that the involuntary action of the same mechanisms will tend to become abnormal. Pseudobulbar paralysis is the disease of the geniculate bundles which, we have already seen, is particularly prone to be accompanied by the phenomena of rire et pleurer spasmodiques.
"It is clear, then, that the more absolute the faciorespiratory paralysis, the more exaggerated is the involuntary innervation of the same mechanism. In this connection Monrad-Krohn has shown that the emotional innervation is often distinctly exaggerated on the paretic side in hemiplegia, and has proved (by the 'slow-motion' cinematographic camera) that emotional movement is actually quicker on the side showing voluntary paresis. On the other hand, for the exhibition of 'uncontrollable' laughter or tears a degree of volitional paresis or paralysis is not quite essential, though it is certainly usual; the involuntary action of a normal laugh may break down normal control; the quivering lip of the child is indicative of a balance between the action of the voluntary and the involuntary processes which may be tipped over in either direction by a trifle.
"(2) Involuntary Control. The careful experiments of W. G. Spencer, in 1894, determined the existence of four paths from the cerebral cortex to the respiratory mechanism. Of these, one is undoubtedly the voluntary path just mentioned, from the motor cortex via the genu of the capsule; its stimulation produces, in the ape, a sort of holding the breath, or, as Spencer calls it, overinspiratory tonus. Two of the other tracts follow an entirely different course; one is an 'arresting' and the other an 'accelerating' path. The former arises from the under surface of the frontal lobe, the latter from the sensory cortex. Spencer has traced the two throughout their course; they come together towards the middle line at the mesial aspect,of the lower optic thalamus, bordering on the third ventricle, and run down, near the midline of the tegmentum, to the medulla. Both are far removed from the voluntary tract for respiratory innervation in the capsule and crus. More exactly, the route followed by the arresting path is from a spot on the under surface of the frontal lobe where the olfactory tract runs into the temporosphenoidal lobe, along the 'olfactory limb' of the anterior commissure (where it decussates), by the side of the infundibulum, past the nucleus ruber below and external to the aqueduct in the plane of exit of the third nerve, and so to the medulla. As for acceleration, commencing especially from point on the convex surface of the cortex within the sensorimotor area, the effect may be followed back through the lenticular nucleus where it borders on the outer and ventral portion of the internal capsule; the strand runs at first externally and then ventrally to the motor portion of the internal capsule, and so reaches the tegmentum. The lines from the two sides meet in the interpeduncular grey matter at the level of and just behind the plane of the third nerves.
Wilson believes it is a feasible speculation that these are the paths for emotional activation of the f aciorespiratory mechanism. They are separate from the paths for voluntary control; they come towards the midline in the regio subthalamica and tegmentum; stimulation of them produces unvaryingly the phenomena of arrest and acceleration noted above. As far as the respiratory element in involuntary laughing and crying is concerned their appropriaté excitation and inhibition will explain the mainly expiratory character of the former and the mainly inspiratory character of the latter.
Wilson's general conclusion may be couched in the following terms: "There are corticifugal paths to the faciorespiratory centers in the pons and medulla that are independent of the voluntary, cortico-ponto-bulbar tracts to the same nuclei; on excitation they will either arrest or accelerate, i.e., interfere with, the normal rhythmic activity of the respiratory center; the available evidence warrants the speculation that they are the routes taken by emotional impulses to modify the f aciorespiratory synkinesis in the direction either of laughter or the reverse. Their exact course remains for further substantiation; it is perhaps noteworthy that they make their way separately towards the midline skirting the lower optic thalamus (in the case of one) and passing by the lower regio subthalamica to the tegmentum, and so to more caudal levels of the neuraxis."
Wilson is of the opinion there is more to be said for the participation of the cortex in the production of abnormal emotional activity. "We cannot take it that the cortical origins of the arresting and accelerating respiratory tracts of Spencer are physiologically, though anatomically, separate, and we may ask-using Mills' expressionwhere is the rendez-vous? In an ingeniously developed argument, that veteran neurologist contends that in the right hemisphere, mainly, in the midfrontal region, are centers for the representation of moveinents especially concerned with the expression of emotion. He gives the term 'movement' a broad significance, as applying both to skeletal and to visceral, vascular, and secretory activity. On the other hand, Bianchi, whose claim to speak with authority also is acknowledged declares that 'to maintain that the frontal lobe plays a part in the essence and mechanism of the emotions . . . is a bold hypothesis in which there is a good deal of mere conjecture and certainly no basis of proof.'
"Be all this as it may, and however much in the matter is still obscure, our facts have led us to suggest that there are corticifugal paths for the expression of the emotions via the faciorespiratory apparatus, distinct from those for voluntary innervation o the same nuclei, and as necessary corollary we presume the existence of a cortical nodal point coordinating them. Its situation is at present indeterminate, yet it is likely to have some definite position." In this connection Wilson echoes with approval the works of Mills, who declares he is not one of those who believe that the problem of emotion, or of any other great mental process, is to be explained by regarding it in some vague way as a complex expression of the action of the cerebral cortex as a whole.
"There is clinicopathological, and experimental, evidence suggesting that nonvolitional control over the normal activity of the of faciorespiratory mechanism is exercised from the cortex by routes that pass separately downwards to come together towards the midline in the regio subthalamica and tegmentum. It is not certain that these actually pass through the thalamus in man, though it is understandable that some thalamic lesions may be so placed in that ganglion as to interfere with them as a vicinity effect.
We have no information as yet to show these paths are interrupted by a thalamic relay, nor is it known that emotional impulses can pass from sensory to motor side at this level; it is possible, perhaps, but not probable."
Inasmuch as practically every observer has called attention to the fact that under certain situations of attention (distraction) this breathing behavior is partly or entirely, overcome; and under certain emotional stimuli it may be made worse; and further that in practically all cases the disordered breathing behavior ceases during sleep, it is fairly certain that bulbar implications alone do not offer a complete answer looking toward an elucidation of the syndromy under consideration.
When one reflects for a moment upon the phyletic history of the gradual integration of speech into the respiratory mechanism and when one studies ontogenetically the respiratory behavior from the initial cry of the child at birth up through its evolution into the dynamic utilization of speech symbols as expressive of its life's patterns and purposeful actions, socially expressed, it seems quite evident that a purely medullary structural blocking is entirely inadequate to explain the situation. As Turner and Critchley have emphasized, and Wilson shown, and others also indicated, higher pathways, not only of value for respiration per se must be studied, but the respiratory syndromy must be viewed in the light of these higher socially purposeful symbolic activities.
Here it will be apparent to all students of the problems of behavior disorders in encephalitis that one enters upon an enormous terrain. The lines of inquiry spread out in every direction. They become pluri-dimensional and almost infinite.
Inasmuch as the more astute as well as the more superficial students have called attention to the "emotional" situation, the latter being satisfied with the word "hysteria," the former not satisfied with an etymological resting place but insistent upon deeper correlations between structure and function-witness Vogt's suggestions in the "Heidelberg" paper as to the subtle relations of so-called 'hysteria" to striatal pathology-a certain sketchy following out of a few of these lines may not be without value.
I once observed an interesting respiratory syndrome in a pharmacist, 23 years of age. He came to the Post Graduate Hospital Clinic "barking like a dog." His bark was a dramatic performance. It had gradually developed over a period of somè 2-3 years. Nothing short of a phonograph record could portray the sounds he emitted. They appeared in compulsory episodes lasting from 5 to 30 minutes.
Conceiving the possibility that what I heard at the time was a condensation product, I inquired whether if previously the sounds had been as they were at the time observed. No! they had been more elaborate the previous year but phonetically still unrecognizable. Pushing the history a step further backward a phonetic semblance to recognized vocables became recognizable and then still further back it was plain he was saying-a year earlier-half aloud and half to himself-" No I won't!-No I won't -No I won't! " and then further back at the beginning of his difficulty the actual verbal formula was recalled. "No, I won't masturbate." Thus in the space of two and a half years-an orignal statement "No, I won't masturbate," became by gradual condensation the "dog-like bark" heard in the clinic. Naturally this was not air learned in an hour, nor in less than a dozen hours of careful and detailed study, not only of conscious but of unconscious material.
This observation might not seem pertinent but those interested need- but read Runge's (l.c.) very carefully detailed report of an encephalitic respiratory syndromy, which he studied by the hypnotic method, to see that Runge came to the conclusion that the respiratory behavior was a representation of what he terms a "larvated masturbation."
Personally, I believe Runge is correct, but also I think that further study would have shown it was more than that, as a psychoanalytic study of both cases here presented shows that the displaced masturbatory craving was but a part of the respiratory syndromy. The report of Case I-already indicated in the earlier pages of this study-gives some of the evidence showing that such a displacement of energy from the genital to the respiratory area was present and that other ontogenetic sexual stages were represented, even to well defined incest wishes. A well defined brother incest wish was evident in the unconscious of Case II. It appeared in the very first dream related as will be discussed.
Then to follow out another line not quite so well known in contemporary neurological literature, but almost a commonplace in psychoanalytic literature, the problem of "obscene language" as a' displacement mechanism to "anal erotism" comes up for investigation.
Abraham, Ferenczi, Jones and others have analyzed the situation in full, as a contribution to character formation. Case I was exceedingly profane and obscene in the earlier months of his illness (see Burr's comments concerning "degeneracy" of this case). Scores of reports are available concerning this "obscene" language behavior in the "psychotic" reactions of the encephalitic, particularly in the "schizoid" types, where the analogies to schizophrenic obscenities are obvious. Many of the nose grimaces seen and sundry obscene words heard in Case I were loosened bits of early anal-erotic functioning pried apart from an integrated personality by the encephalitic process and through diaschisis came into pantomimic expression, passing the broken down Super Ego (censor) mechanism probably through cortical blocking from some organic substratum. In so far as recovery took place it was evident that the blocking was partial aud not global and a resynthesis of the so-called "normal" personality emerged. Here we may make a concession to Hollingworth's utilization of, Herbart's term "redintegration" to define a phase of the recovery process. Thus the patient could now utilize a symbol of "smearing" an enemy, in much the same sense as it would be used on the football field when the opponent's attack was "smeared "-withot recourse to a less elegant form of expression.
The frequent "nose blocking" in this and other cases is in-psychoanalytic terms, possibly referable to "smell" and displaced "anal eroticism."
 parkinson encephalite
It would be premature to attempt to postulate here the numerous structural problems which I have thus briefly summarized in other terms. Every student of neurology knows that the original striatum was of olfactory origin. Here, as Kappers and others have pointed out, was the nucleus of the paleoencephalon, which played so marked a rôle in the behavior of the animal phylum before the distance receptors began to accumulate their end stations in the gradually evolving neo-encephalon. How (diaschisis) dissolution of function can reactivate these old mechanisms and thus bring these nose behaviorisms into prominence I shall not attempt to formulate, the problems are too intricate. I shall only state that they are there awaiting analysis in the nasal tics, olfactory hallucinations, food phobias, schizoid oral activities, and possibly some epileptiform associated reactions.
In a communication made before the Research Association of Nervous and Mental Disease in December, 1925, I have discussed at length certain aspects of the similarities and differences between the psychotic manifestations of "post encephalitic " and "schizophrenic" behavior and there called attention more specifically to olfactorally determined bits of conduct along lines paralleled by Sullivan and others who have investigated the "oral erotic" behavior of schizophrenics. My Case II, with her persistent finger sucking difficulties (lime drops, cigarette smoking, fish mouth lip appositions, etc.), offer material of a less complicated character as data for such investigations. These nasal-oral combinations are primitively associated phyletically, and hence ontogenetically. One need not go into the steadily advancing mass of animal behavior data to show how important these early biological conditionings are. All that can be done at this time is to note their significance as immense fields for study as the monographs of von Kries, Parker, Henning and others indicate. Thus nasal-oral behavior cannot be entirely overlooked since they form such an important part in "respiratory" behavior, seen from the standpoint already brought into the field by Wilson's study, quoting Bell anent the "facial" nerves as an efferent factor in respiratory activity.
Furthermore, whereas this study does not concern itself with the polyuria so frequently observed in the larger group of the encephalitic syndromy a few cases of a "whistling," "hissing" respiratory type of so-called "tic" might be put on record. These were plainly traceable, psychoanalytically, to the urethral-erotic type of diaschitic phenomena. One patient very clearly showed that "whistling" and the wish to urinate were correlated. There was a distinct proportion which could be stated "the more he whistled the less he urinated and the less he could whistle the more the urge to urinate" (running water). Cases of Wimmer and Gabrielle Lévy have already been cited in this connection.
(5, 6, 7.) Thus we are led to the consideration of (5) the broader mechanisms of the emotional releases through the speech mechanism, (6) of the highly complex relationships of visceral component involvements in the encephalitic syndromy and their behavior manifestations, which opens up the enormous territory so actively under investigation by students of the problem of the psyche and the vegetative nervous system (extrapyramidal regions), to mention only Küppers, Hess, Lotmar, and finally (7) of the metapsychological problems investigated by Freud and his school in the formulations of the Super Ego, the Ego and the Id.
It would be presumptuous on my part to claim that the present discussion approached any final statement of these situations. All that I hope to accomplish here will bt. to offer a glimpse at certain features which are believed to be of service in the accumulation of data looking forward to a better understanding of the subtle, intricate and highly condensed mosaic that make up human behavior, especially as revealed in the disordered state specifically under investigation.
Baron Constantin von Economo1876 - 1931

Sleep as a problem of localisation von Economo 1930 - pdf