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).
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.
SOMATIC PATHOLOGY OF THE
RESPIRATORY SYNDROMIES
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.
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."
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.
Encéphalite léthargique
Cruchet, Moutier, Calmettes Soc méd hop
Paris 27 avril 1917
