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Lethargica Norman B THE CANADIAN MEDICAL ASSOCIATION JOURNAL 169 should be well washed out in one hour with In conclusion, we might say that the termina- 5 per cent. solution of soda bicarbonate and a tion of gestation, which is our last resort, will Murphy drip of 5 per cent. solution soda bi- probably be our sheet anchor until prophylaxis carbonate and 6 per cent. solution of glucose by education and instruction so elevates the mass employed. Veratrum vireli may be tried for steadying the heart action. Morphine sulphate of the people that these states of toxtemia during a grain with atropine sulphate 1-100 grain or pregnancy will be rare instead of relatively ether given to control spasms. common. THE EPIDEMIOLOGY AND DIAGNOSIS OF ENCEPHALITIS LETHARGICA NORMAN B. GWYN, M.B. Toronto MUCH confusion has arisen through our has been identified, to the satisfaction of the misconception of the. terms Epidemiology epidemiologists at least, for several hundred and Epidemiological relationship, the endeavour years,* one fairly conclusive detail is alwavs of of the epidemiologists to prove to us that the material assistance in the identification-epidemic epidemics of encephalitis, of poliomyelitis, cerebro- paralyses are rare at best,-the meningitides, spinal meningitis and influenza, have frequently poliomyelitis encephalitis, and the food poison- occurred in close relationship in the world's ings practically comprise the whole class, the histoty, has led to quite unlooked for conclusions. epidemiology of these three is strangely similar The epidemiology of encephalitis is inextricably and seems as regards all of them to be closely bound up with that of polio-myelitis and with that bound up with that of the more or less well of cerebro-spinal meningitis and of all in turn has recognized sweats and -catarrhal fevers of the it been said that they preceded, accompanied or middle ages. Perspective and elapsed time have followed some more or less generalized febrile had much to do with the developement of the idea epidemic, influenza-like in its symptoms and char- that encephalitis depends in any way upon some acter. An undoubted epidemiological relationship preceding infection. does exist, however, and in four hundred years of Realizing these points it seems better to come records of medical history there are to be found quietly down through the ages, to admit the many interesting accounts of epidemic paralyses, many interesting associations of the many stupors, and vague nervous disorders, occurring obscure affections of the nervous system with each in more or less close connection with generalized other and with other epidemic disorders, but to waves of infections which are considered to have reserve one's critical analysis for the age of more been influenza; in many instances the epidemic accurate observation; to one epidemiologist for nervous disorders preceded the outbreak of the example, deductions in such a well-known disorder more widespread, grippe-like fevers; paragraphs as influenza, are to be considered unreliable if from Hippocrates would well describe the epi- drawn from description made prior to the great demiologic relationship of encephalitis and in- epidemic of 1889-90,2 much the same can be said fluenza in England in 1918 and is no less ap- of encephalitis lethargica; the conditions de- plicable to the state of affairs in Canada in the * According to Hecker, "Hauptkrankheit," "The head winter of 1919-1920.1 disease," a pernicious fever with inflammation of the brain, Encephalitis as a specific disease and not was well recognized in Germany and referred to long before merely as a complication of some acute infection the sixteenth century. He regularly refers to it as en- cephalitis. He considers an epidemic in France in 1482 Symposium at the Academy of Medicine, Toronto, as encephalitis but the description would fit any acute 1920. infection. 170 THE CANADIAN MEDICAL ASSOCIATION JOURNAL scribed may have been and have been cerebro- disease), begins at this time; without doubt much spinal meningitis, poliomyelitis, food poisonings, confusion existed, the paralyses occurring epi- or simply the severe nervous type of many demically must have puzzled the observers of the different fevers. The references made to "epi- day, and one recollects that in 1918, boltulism demic paraplegias occurinig in a winter season was the diagnosis made in England for the first and preceding a burning fever of the spring,"1 cases of encephalitis, to be followed by the may be taken as an example of early epidemio- actual occurrence of botulism in the United logical association, an association, one part of States. which the "epidemic paraplegias?' seems likely to Nearly half a century later, 1657, the cycles have been encephalitis, poliomyelitis or menin- of the various diseases we have been above gitis, and through the centuries one finds many referring to cut into each other again; influenza such records of the occurren.ce of what mr.ay of 1657-8 "affected man most grievously in their have been this supposedly n.ew disease "Nona" of brains and nervous stocks" according to Willis, the last few years:3 As alread.y mentioned, the and epidemic lethargies existed at Copenhagen; fact which most impressed itself upon the early four years later, Willis's fever "infestuous to the writers was that these disorders seemed to recur brain and nervous stock" is described. Willis in such close relationship to the sweats and is said to have identified this fever with the catarrhal fevers, the commonest epidemic dis- German Krielbelkrankheit, no very close associa- orders of the dark and middle ages, and some tion with preceding or following catarrhs is of which uncdoubtedly were the ever returning noted with this rather definitely labelled disorder. * waves of influenza in its many forms. Needless Two hundred years of epidemiological relation- to say but few reliable details exist from these ships between sweats, influenza, and the several centuries. erratically described disorders of the nervous It is not till the 15th century that we can system, bring one to a point where the confusion make much use of described conditions: 1481-2, caused by epidemiological deductions becomes 1528-9, were again years of suggestive association very evident; Heine's description of infantile of paralytic diseases, diseases the main features paralysis appeared in 1834-5, epidemiological of which were "somnolence and inevitable stupor,"4 associations of infantile paralysis with catarrhal with the constantly recurring sweats; of more fevers and influenza is recognized at once, as- than passing interest is the attempt in the 16th sociations which like those of encephalitis leth- century to show that the cause of some of these argica allowed the nervous disorder to either epidemic paralyses was some food intoxicant, precede or follow the more general epidemic, fish or rye (ergotism), and from this time on we with as much reason as is used in discussing the have the state of affairs as in 1918-epidemic xetiology of encephalitis, could one ascribe infan- paralysis, ergotism (raphania), (mal mazzucco), tile paralysis to the virus of influenza. as a diagnosis, like the botulism of to-day, and At this period of medical history, symptoms with the in.fluen.za preceding or following. of specific fevers due to involvement of the Epidemic stupor 1545-6 and the head pain nervous sy,stem, and such conditions as ergotism, in Germ.any in 1543-46 are put forward by sorre botulism., cerebro-spinal meningitis, encephalitis, writers as encephalitic manifestations, these poliomyelitis were but indifferently differentiated, conditions may have been almost anything., they the epidemiology of all the latter conditions is seem at least to have existed apart from other hopelessly obscure; approaching our own times epidemics; to call a disorder of 1567 an "avant- some clearer epidemiological light is shed, it is a coureur" of the great influenza of 1580, is a delight to read, as above mentioned, in one kindness to history, it does service, however, in author's detailed account of the occurrence of showing again that even if, "during the w.inter influenza "that for practical purposes the epi- and at the beginning of spring there was a "quan- demiologist must not begin his study earlier than tity innumerable of paralyses" that at le.?st they 1889-90,"6 it is quite apparent from the history seemed to have an independent existence.0 of all epidemics that in many instances cerebral 1595 saw the "Krielblekrankheit" co-existing in Germany with epidemic catarrh, this disorder, * The description by both Sydenham and Willis is like the mal mazucco of the Italians, was usually of a disease much resembling typhoid, both give post mortem details, however, and the absence of intestinal ascribed to food intoxication, and the history lesions is commented upon by Creighton. There is no of botulism, ergotism, raphania (the radish distinct resemblance to the present day encephalitis. THE CANADIAN MEDICAL ASSOCIATION JOURNAL 171 complications have been magnified into new VanErmengen at the same time by his discovery diseases as seen in some influenzas, typhoids, of the bacillus botulinus showed clear that an pneumonias, it is also just as apparent that occasional epidemiological relationship is no cerebro-spinal meningitis and poliomyelitis have proof of xetiological idenity. From this time on frequently been confused with encephalitis: ergot- it has seemed possible to determine what for ism in the earlier years, and in the later years, many centuries must have confused many botulism, have added materially to the difficulty clinicians, namely, that the epidemic paralyses of determining a clear history of the epidemiology so often referred to, so often associated with of encephalitis. other epidemics were of four distinct types, By the end of the 19th century clinical medi- poliomyelitis, cerebro-spinal meningitis, the food cine in its progress was beginning to show its poisonings, (botulism, raphania, mal mazucco, influence on public health problems, polio- krielbelkrankheit,) and the condition we are myelitis, well identified, seems to displace en- to-day discussing, encephalitis lethargica.
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