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The Chronic Residual Respiratory Disorder in Post-Encephalitic Parkinsonism

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The Chronic Residual Respiratory Disorder in Post-Encephalitic Parkinsonism J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.31.4.393 on 1 August 1968. Downloaded from J. Neurol. Neurosurg. Psychiat., 1968, 31, 393-398 The chronic residual respiratory disorder in post-encephalitic Parkinsonism ROBERT KIM From the Neurological Unit of the Boston City Hospital and Department of Neurology, Harvard Medical School, Boston, Massachusetts, U.S.A. Respiratory disorders were a prominent feature ofthe 3. Respiratory tics These included yawning, hic- acute phase in many outbreaks of epidemic lethargic cough, spasmodic cough, and sniffing. encephalitis in 1918-25. They occurred both in Though reporting only the more dramatic dis- the acute stages of the illness and as sequelae. They orders, Turner and Critchley (1925) pointed out were reported in conjunction with all the other that slighter dysrhythmias were not uncommon. common manifestations of the residual post- Jelliffe's monograph (1927) contains a complete encephalitic symptoms and occasionally were the historical review, and reports two further cases only manifestations of the syndrome. Many of with psychopathological studies. the disorders in early stages of the disease were Of the many respiratory disorders reported, guest. Protected by copyright. complex, compulsive tics such as reported by perhaps the most dramatic were observed by Wolff Babinski and Charpentier (1922). One of their and Lennox (1928). The episodes they observed patients had an episodic disorder occurring more would begin with increasing hyperpnoea leading to frequently in the evening and consisting of contrac- apnoea. During the hyperpnoeic phase, the face tion of the nares followed by slow respirations, as took on a look of anxiety and there was an increas- low as six per minute, then interruption ofrespiration ing taughtness of muscles with twisting and turning in the inspiratory position and finally prolonged of the body. During the apnoeic phase, the patient snorting respiration through the nose as if trying turned cyanotic and then fell unconscious, and to dislodge a nasal plug. It was noted that the patient finally had a grand-mal seizure. The authors con- could exercise some control over the disorder but sidered the possibility that the whole sequence could not stop it completely. The tic-like nature of was a manifestation of seizure disorder but con- the phenomenon at first led some to the conclusion cluded that the syncope was due to apnoea and a that it was hysterical, though its association with Valsalva's manoeuvre and that the seizure was the other compulsive manifestations of the disease secondary to hypoxia. and the occurrence of many other similar cases in Since the 1920s there have been few reports. post-encephalitic patients disproved this assumption. Nugent, Harris, Cohn, Smith, and Tyler (1958) By the time Turner and Critchley (1925) wrote noted decreased maximum breathing capacity and their paper on respiratory disorders in epidemic dyspnoea in 50% of Parkinsonian patients. These encephalitis there had been many case reports of authors felt this was due to rigidity of chest wall http://jnnp.bmj.com/ similar complex compulsive disorders in respiration. muscles and noted that exertion could increase the These authors present a good review of the French maximum breathing capacity beyond the volitional and English literature to that time. Respiratory ability to do so. Recently, De La Torre, Mier, and disorders were classified intothe following categories: Boshes (1960) mentioned irregularity of respiration 1. Disorders of respiratory rate Tachypnoea was in Parkinsonian patients and confirmed an incidence the most common disorder and was noted to be of 50% of Parkinsonians with reduced breathing either continuous or episodic. It could occur at any capacity. Grewel (1957) quotes a paper by Schilling time, sleeping or awake, with rates as high as 100 per in the German literature which characterizes on September 27, 2021 by minute. Slow breathing was less common. Parkinsonian 'vegetative' respiration as lacking in 2. Dysrhythmias or disorders of the respiratory the natural undulations and as being wider and more rhythm Among these were included Cheyne- irregular. Grewel reviewed the speech disorders in Stokes respiration (rare), breath-holding spells, Parkinsonism but stressed disturbance of facial and sighs, forced or noisy expiration, and the inversion lingual and pharyngo-laryngeal muscles. of the inspiration-expiration ratio. Schmidt and Kaniak (1960) noted that many of 393 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.31.4.393 on 1 August 1968. Downloaded from 394 Robert Kim their patients with stereotaxic lesions (site of tasks such as breath-holding, singing, speaking, and ablations not mentioned) developed pulmonary reciting the Lord's Prayer with as few breaths as possible. complications. They noted reduction in respiratory Subjects were asked to cough voluntarily and the reaction performance, especially in the ability to cough and to spirits of ammonia introduced into the system was to breathe deeply. Petit and Delhez (1961) studied tested. At the same time that the respirometer recorded diaphragm and intercostal muscles with the electro- airflow, an abdominal cuff recorded expansion and myogram and report, in Parkinsonian patients, contraction of chest and abdominal motion. In this way muscular motions of breathing could be correlated with that diaphragmatic muscles appear normal or near airflow. normal. while intercostal muscles showed constant discharge through inspiration and expiration and it RESULTS was thought that this inteifered with respiratory function. Only when the patient was extremely 1. RESTING RESPIRATION Rate All anxious Parkinsonian did the diaphragm show continuous patients had rapid respiratory rates compared with discharge. controls. The rates of normal Descriptions of individuals ranged respiratory disorders of the post- from eight to 13 respirations per minute and encephalitic syndrome have dealt almost exclusively averaged 11, while patients with post-encephalitic with episodic phenomena occurring within several Parkinsonism ranged from 13 to 31 and averaged years of the time of lethargic encephalitis. The 19 (Figs. la and b) (Table I). respiratory status in patients with long-standing disease Regularity of amplitude of respiration In those has received little attention. The present study subjects in whom a two-minute consecutive was undertaken to characterize period resting respiration of respiration uninterrupted by signs or disorders in the long-term post-encephalitic Parkinsonian of could be patient. respiratory rhythm measured, it was A previously unreported guest. Protected by copyright. disorder of vol- found that Parkinsonian patients had more regular untary control of automatic respiratory functions than controls. This would is noted. respirations reflect the absence of regular undulations seen in normal METHOD Nine patients with Parkinsonism were studied. Four of these patients (M.H., N.T., M.W., L.C.) had all of the following features; a history of influenza between 1918-25, early onset of the Parkinsonian syndrome between the ages of 16-40, with well-documented oculogyric crises. One patient, M.S., had a history of influenza, onset of illness before the age of 50 and, in addition to the usual features of Parkinsonism, she had aniscoria and unreactive pupils. The mother of the sixth patient (J.H.) had influenza during the seventh month of gestation and his Parkinsonian symptoms started at the age of 22. J.G. had a history of influenza during the first world war and had onset of Parkinsonism at the age of 55. All of these seven patients have been fully FIG. la. An example ofnormal repiration in a 21-year-old evaluated as in-patients of the Neurological Unit of woman. There is considerable variation in the amplitude of http://jnnp.bmj.com/ Boston City Hospital or related chronic service of the respiration, which occurs in undulations. Long Island Hospital. Of the two remaining patients, D.S. had influenza in 1916 and developed Parkinsonism in 1956, and J.M. the last, had no history of influenza, onset at the age of 45, and all signs of Parkinsonism are minimal. The apparatus consisted of an ink-recording respiro- meter. A mask rather than a mouthpiece was used, so that subjects could speak the during tests and so that on September 27, 2021 by bucco-facial and lingual motions would be left intact. A soda-lime carbon dioxide absorber was used and was fed _ oxygen into the system so that recordings could 0 60 be taken over long periods (up to one hour without 120 time(sec) interruption). Breathing in this apparatus was not FIG. l b. An example of post-encephalitic respiration. distressing and early anxiety rapidly subsided. Readings Respirations are rapid with reduced variation in amplitude of resting respirations were taken as well as some simple and there are two pauses. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.31.4.393 on 1 August 1968. Downloaded from The chronic residual respiratory disorder in post-encephalitic Parkinsonism 395 TABLE I TABLE II RESPIRATORY RATE1 REGULARITY OF RESPIRATION1 Post-encephalitics Controls Patient Mean amplitude Per cent deviation (mm) from mean patient resp./min. patient resp./min. Post-encephalitics J.G. 22 T.J. 10 M.H. 20 H.K. 13 J.G. 250 11-6 J.H. 16 E.O. 8 M.H.2 7-8 21-4 N.T. 20 P.G. 13 J.H. 15-5 4-7 M.W. 31 H.F. 9 N.T. 25-5 5-7 D.S. 18-5 J.R. 13 M.W. 23-3 4-3 M.S. 16 D.S. 20 5 7-7 J.M. 13 Average 11 M.S. 27-4 5 0 L.C. 16 Spread 8-13 Average 8-6 Average 19 Spread 13-31 Controls I Post-encephalitic patients showed increased respiratory rate. T.J. 27-5 13-4 H.K. 22-3 9-8 E.O. 19-7 14-2 respirations. To arrive at a numerical measurement P.G. 29-1 134 H.F.
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