Miss Y. was referred to me on February 8,
1926, by Dr. L. Loeb of Philadelphia through the
suggestion of Drs. W. G. Spiller and A. M.
Ornsteen of the same city.
At this date she was twenty-six years of
age, single. The family history is of interest.
The father was born in Germany of Jewish
parentage. He has a distinct psychoneurosis,
chiefly gastrointestinal in its manifest
content. The mother wàs born in the
United States of Jewish parentage. There are
three children in the family -a son of
thirty-three, married, with two children,
reported healthy; a son of thirty-one who had a
encephalitis while in the navy serving in the
World War and has been psychotic for, at least
five years, diagnosed as "dementia precox type";
the patient is the youngest child.
There are other family disturbances in
addition to the father's neurosis and that
already outlined for the brother. llly defined
histories of two psychotic members of the
mother's family are indirectly learned of. There
is no history of diabetes, goiter, endocrine
anomalies, tuberculosis, nor alcoholism on
either side thus far obtainable.
Personal history: The patient was normally
born, walked and talked at the usual period,
read at the age of five to six. She has remained
a thumb sucker to the present time, using the
middle and ring fingers of the right hand. She
had whooping cugh at the age of seven months,
measles, chickenpox and diphtheria at five. She
had no history of infantile enuresis, did bite
her finger nails, did not walk in her sleep, but
did talk in her sleep. There is no history of
stammering or stuttering. There were no other
infantile neurotic traits of outstanding
character.
She passed fairly well in her studies, went
to the third grade in High School by seventeen
and went to a business college for a short
period. There are no signs of congenital lues,
she has never lived in the tropics, suffered any
severe accidents, is 5 feet 4/ inches in height
and now weighs 130 pounds; her weight was 152
pounds four years previously. She had a general
pyknic habitus. She began to menstruate at
thirteen and one-half years , and has always
been regular in this function. She has smoked
since about sixteen to seventeen years of age
but never excessively; does not always
inhale.
History of illness: In December, 1924, she
was in excellent health. She was an outdoor
girl, enjoyed golfing, motoring, dancing, was
popular, made friendships, had healthy social
contacts with young men and was engaged to be
married when she was taken ill. She was helping
a brother during the Christmas holidays in a
retail store and was very busy when one night
she awakened out of her sleep "in a sort of
chill or spasm" as she expressed it and was
afraid she was going to be ill. She was at the
home of a cousin, used a hot water bag and in
spite of herself felt an uncontrollable urge to
talk to her cousin. This she did all night long.
She narrated all sorts of incidents that were
connected with her work at the store in a
feverish, turgid manner, connected, but
hypomanic in its intensity. Then she began to
notice things upon the wall. It seemed to be
alive with little black bugs crawling in every
direction. These then seemed to cover
everything, including herself, her arms, and her
chest. This hypomanic state lasted
uninterruptedly for about three days, and she
was quite, solicitous of her condition and made
frequent complaints that no one was interested
in her and no one would pay any atention to her
dire distress.
She then saw double and was confined to her
bed for about six weeks. During this time
everything seemed blurred and confused. She was
restless at night but sleepy all during the day
time. There were no ascertainable paralyses but
she was weak and distressed. She was better by
the middle of February and then had a slight
relapse. She was always tired and depressed and
consulted a local specialist who, according to
her story, told her she was "filled with germs"
and who started to clean out her gall bladder.
This procedure was extremely distressing and
after the fourth or fifth treatment she could
not stand it any longer and Dr. Loeb was
consulted. At this period she was asthenic,
emaciated, had a severe leucorrhea, and had
attacks of tremor of the entire bodily
musculature.
ByJune, 1925, she was able to lie in bed in
the sunshine and then the disordered breathing
began. At first she had attacks of rapid
breathing four to five times a day. The attacks
would last four to five minutes only during
which she felt that she was unable to get her
breath-" her windpipe was closing on her." She
had typical anxiety attacks, would rush to the
window to get her breath in a veritable attack
of air hunger. Her appetite was good, but she
could not sleep. Hypnotics were then ordered and
were used all summer.
They were chiefIy bromides (Somnos). She saw
Dr. Spiller in July and Dr. Ornsteen later. Her
nose seemed to be stopped up and she could not
breathe through her nose.
The breathing spells then became more and
more frequent and by Septenber of 1925 had
become almost continuous. She had f requent
crying spells, ungovernable yawning and great
prostration. The leucorrhea became more and more
annoying and she used douches to control the
itching which was constant. This leucorrhea had
been bothering her off and on for sometime.
Regarding this leucorrhea some notes sent me
by Dr. L. in February, 1926, indicated, that
this was an old difficulty. Dr. L. writes:
"Shortly after Miss Y. had entered a school in
Boston (1918) she had some abdominal pains. She
had an acute salpingo-oöphoritis on the
left side-with appendicular involvement as well.
The appendix was removed and part of an affected
ovary of the right side. Later she had a
curettage and adhesions which had caused a
uterine displacement after the original
operation were relieved. The microscopical
examination of the discharge was reported
negative."
Dr. L. gave me a summary of her condition at
the time of her acute illness. She had the
beginnings of an acute exophthalmic goiter with
characteristic circulatory disturbances and
small tumor. The exophthalmos was bilateral,
l>r, Stellwag and v. Graefe positive. Pupils
sluggish, diplopia, and visual fatigue. There
was a fine involuntary tremor which increased on
excitement. The patient was talkative and
resentful and would talk night and day. Insomnia
was marked and was controlled by hypnotics.
These Dr. L. emphasizes were the most marked
signs of her encephalitis attack. She began to
lose weight, and then went through a deep
lethargic phase in which she could not be
aroused and had a pronounced amnesia for all the
events of this period.
Dr. L. further noted the following:
Three to four months after her recovery from
the acute phase she developed the following
sequelae.
(I) True respiratory disorders. Polypnea,
bradypnea, apnoea and periodic respiration.
(8) Quite recently she has developed some
hysterical phenomena.
My own neurological examination of February
8, 1926, briefly narrated showed the
following:
Some nasal grimacing related by patient to
her difficulty in breathing but no anosmic or
hyperosmic difficulties.
Sight O.K. No hemianopsia or fundus changes
and no scotomata or restriction of visual
fields.
Ocular muscles freely movable, no present
diplopia. Pupils equal, slightly sluggish to
light, r=l.
Trigeminus, facial, auditory and other than
vagus nerves O.K. on general examination. No
altered oculocardiac reflex. Sialorrhea is
profuse, epecialIy at the end of the
yawning attacks.
Upper extremities no pareses, nor
anesthesiae, twitching and marked hypertonus and
some rigidity. All arm reflexes + + +. No
tremors save after some of the respiratory
seizures when the patient had a generalized
shivering reaction related to cyanosis, but she
says she does not feel cold. No taxes,
adiadokokinesia, or sensory defect.
Polyuria and polydipsia are both present.
Slight stiffness of parkinsonian type. Patient
states she feels as though "strapped to a board"
when in bed. Is tense all over. No cogwheel
phenomena.
Lower extremities as upper. Increased tonus,
partial rigidity, increased patellar and ankle
jerks + -j-, no clonus, no Babinski, Oppenheim,
Gordon or Chaddock signs. No sensory
disturbances. No gait disturbances but patient
has slight propulsion-mild parkinsonism. No
trophic disturbances, dermographia or Sergent
line. Irregular tachycardia, variable, but no
murmurs and no pulmonary signs. Larynx O.K.
The respiratory disturbance is extreme. It
is almost constant. The patient is in extreme
exhaustion from her breathing difficulties. She
pants for breath as it were.
The attacks are in reality paroxysmal but
are so frequent as to seem persistent. As one
watches her breathing one is forcibly reminded
of a fish gasping for breath. She breathes on
the average 35 to 45 times to the minute, the
mouth opens, the lower jaw is pulled down, there
is a fairly long inspiration and a sharp violent
expiration. This goes on for from two to five
minutes, then there are several gaps or
yawns, and if a long satisfactory
yawn is obtained she is over the attack
for from two to five to fifteen minutes, but
more frequently the yawns are only half
satisfying and an apneic phase begins, the lips
get bluer and bluer, the chest, and diaphragm
(see tracings) are held, the hands have a
tendency to clench and she salivates and becomes
absorbed in her agonal fixation and after one to
two to three minutes commences to gasp again for
breath, the color comes back and another gasping
respiratory episode is on.
When a deep yawn seems to terminate
an attack she can converse and narrate her story
or take up any topic brought up. Sometimes these
free intervals last five to ten to fifteen
minutes. The longest in my office has not been
over fifteen minutes although at times she
states she has a free interval of an hour.
The breathing attacks cease when she is
asleep so far as can be ascertained.
These attacks have been stereotyped now for
the three months under observation. I have taken
some cinematograph pictures, parts of which are
here reproduced. As noted shivering tremors
sometimes come on after some of these attacks.
Rarely a day goes by without these.
For the first month no restriction was
placed upon the use of hypnotics. She continued
the use of her hypnotics and begged for
something to give her sleep. Her usual sleep was
rarely more than two to four hours a day.
The day's program was irregular but was
approximately as follows: If she took her
hypnotic, she would sleep from 10:30 at night to
about 4 in the morning; then the breathing
difficulties would begin. She would stay in bed
until noon or 2 or 4-get up for a few hours,
with slight sleeps in-between and again retire
after supper.
Wishing to try out some pharmacological
agents I gave her at various intervals, luminal,
veronal, tr. hyoscyamus, scopolamine, hyoscine,
tr. belladonna. The results were of great
theoretical interest but were not of any
therapeutic value. At one time a mixture of R.
Veronal gm. .02, Tr. Hyoscyamus .01 q. 3 hrs.
led to such a profound regression that the
patient went almost into a drunken coma after
three days medication. She could hardly be
aroused and as she expressed it " felt
heavenly." She clamored for more. I pushed it a
trifle until the patient herself felt a little
alarmed. Tr. Belladonna which A. J. Hall speaks
of as being of service, was of no use and
scopolamine was worthless.
After three weeks of the drugs she consented
to give up all drugs as she realized in a sense
what she was after-speaking in terms of "Nirvana
"-or the "return to the womb" in psychoanalytic
terms, and she realized the significance of her
regressive wish but stated "she was so tired,"
she welcomed death.
In April, through the courtesy of Professor
Twitmyer of the University of Philadelphia I
obtained some pneumographic tracings and append
his interesting report and parts of the
pneumographic tracing.
The subject was placed in the apparatus at 2
:34. p.m. The pneumograph was applied to median
frontal body o line of nipples. The lower
tambour was placed directly beneath it, the
center of the bag about two inches above navel.
At that time the subject was undergoing an
episode of breathing attacks as evidenced by
breathing curves at point "1," and continuing to
point marked "2," at which time it was our
opinion that perhaps we were getting the action
of the lower intercostal muscles rather than
diaphragmatic excursion, so the lower
pneumograph was placed on the subject about four
to six inches below the navel. Immediately there
becomes evident a change in the form of the
curve, the establishment of a higher base line
probably to be interpreted as due to an
involvement of breathing which causes the
release of some of the residual air.
At points "3" to "4" a pulse reading was
made on the girl and found to be 110,
respiration 34 per minute and at the point
marked "5" the subject was seated since she
objected that she was feeling quite fatigued and
the strain of the test was telling on her.
At point marked "6" was the first time that
the girl showed any signs of calm and there was
a slight cessation of terrific breathing
occurring at points " 7," " 8 " and " 9."
At point ' 10" was the first time that we
were able to get her quiet and this state we
produced by supplying her with a book from which
she read silently. Records show that there was a
complete apnea, the cessation of breathing
showing itslf in almost a straight line for both
diaphragmatic and intercostal muscles.
At point marked "11," the girl having
reached complete exhaustion gasped several times
quite audibly.
At point "12," she again resumed an apneic
state, compensatory replenishment of breathing
in evidence at points " 13," " 14," " 15," "16,"
etc.
The record was completed at 3:10. The marks
at the bottom of the record are the metric
swings, the markings being at the rate of 60 per
minute.
While my contacts with post-encephalitics
has been somewhat restricted nevertheless Miss Y
presents an unusual picture inasmuch as her
breathing episodes are not accompanied by any
mental departures. It has been my experience
with previous cases that breathing spells or
other mental disturbances seem to run pari passu
with the respiratory disturbance. However, in
her case throughout our examination she
maintained a very pleasant and docile attitude.
Her sense of humor, her mental alertness and her
general behavior are not affected despite the
fact that the physiological malfunctioning of
the breathing mechanism becomes excessive. At
one time she asked us to release the belt about
her waist, that it was causing considerable
annoyance and preventing her from breathing.
Then she said that she would be most happy if
she could yawn and relieve herself of the
fatigue.
At several times after we had begun our work
and when the curves were running quite high she
was markedly cyanotic and once or twice rolled
her eyes back; eyelids drooping, a spell
definitely epileptoid in character. At no time
was her conversation incoherent or were there
any other evidences of aberration or
hallucination or other abnormality, and no
period of unconsciousness unless the transient
epileptoid attacks to which we refer are moments
of unconsciousness comparable to petit mal. In
order to afford a temporary respite from the
breathing disturbances I asked her to attempt to
vocalize, utilizing some vowel sounds as a
medium through which to discharge the breath.
This exercise is similar to ones which I employ
in orthogenic speech work. This afforded her
considerable relief, controlled the breath and
momentarily synchronized the movement of
intercostal and diaphragmatic musculature.
Encéphalite léthargique
Cruchet, Moutier, Calmettes Soc méd hop
Paris 27 avril 1917
