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the brain stem, especially in the region of the the clinical picture of the lethargic encephalitis Locus Niger and the nuclei of the oculomotor reported abroad, and that he knew of similar nerves. They comment on the resemblance to observations by other physicians. the hemorrhagic superior encephalitis of Wer- Pothier, in the Journal A. M. A. of March, nicke.
1919, reported the clinical details of eight cases, The mortality in France is given as 35 per
with one necropsy. Bassoe reported twelve cases cent, in England 25 per cent, and in Austria as in the Journal A. M. A. of April, 1919, with 1.5 per cent.
complete necopsies of two cases, showing pracThere is a distinct fulminant type, described tically the same pathology in both cases and by these writers, with persistent high tempera- similar to the pathology of the cases reported
from abroad. ture, complete lethargy or intervening delirium, a profound toxic state, with foul breath, tremor, Following a conference with a number of physphincter relaxation and bedsores. Death in sicians, who had had the opportunity to carefully these cases occurs in from eight to twelve days. study the clinical and pathological phenomena as
In concluding the summary of the study of manifested by these cases, Dr. C. St. Clair Drake, those cases abroad, I wish to refer briefly also to
Director of the Illinois State Department of the "Mysterious Disease" of Australia, to which Public Health, promulgated, on March 7, 1919, Wilson referred as probably identical with the
an order, making all cases of epidemic encephalepidemic encephalitis in England, and reported itis or suspicious cases reportable and subject to by A. Breinl in the Medical Journal of Australia, isolation, and assigned me to a study of the cases March 16, 1918. Breinl considered these cases
that may be reported by the physicians in Illinois. as an aberrant form of acute poliomyelitis. Mat
In all I have examined about sixty cases of thewson, in the same journal of October 27, 1917, reported epidemic encephalitis, 41 of which reports as having had under his care seventeen proved to be, from the clinical picture presented patients at the Brisbane Children's Hospital, suf- and the laboratory tests performed, cases of the fering from a similar disease, out of which nun. morbid entity known as epidemic encephalitis. ber eleven died. The onset was mostly sudden. A careful survey of the data obtained from the A child, previously healthy, developed a high study of these cases shows the following interestte erature and was seized with convulsions, ing results: Age incidence. Four cases occurred which continued with intervals of semiconscious- between the ages of 1 and 5 years. Three cases beness for days, the child afterwards lapsing into tween the ages of 5 and 10. Six cases between the stupor. In other cases the onset was insidious, ages of 20 and 30. Seven cases between the ages the child complaining of headache and vomiting, of 30 and 10, and ten cases in ages above forty. and passing into a stuporous condition. Three of The youngest was a baby 9 months of age, and the six patients that had recovered had not re- the oldest patient one of 62 years of age. gained normal intelligence. The spinal fluid in
Sexes affected: Twenty of the cases were male these cases was negative. The report of the histo- patients and twenty-one cases female. pathology of the brain and upper cord of one Seasonal incidence: The earliest case on reccase, described the main changes as a widespread ord occurred in the latter part of October, 1918. congestion of the blood vessels of the brain and
The months of greatest incidence seems to have spinal cord and an infiltration in the adventitious
been December, 1918, and January and Februsheath, with large and small mononuclear cells.
ary of 1919.
The number of cases began to dePractically the first intimation of the existence crease during March, and showed a decided fallof epidemic encephalitis here was when Bassoe, ing off in the latter part of April. during the discussion on influenza before the lu- History of influenza: Of the 41 cases under stitute of Medicine of Chicago, as reported in the consideration 18 gave a history of having had Journal A. M. A. of March, 1919, stated that dur- influenza, from several weeks to several months ing the last few weeks he had seen several cases, prior to the encephalitis. Practically all the which were characterized by marked drowsiness cases were cases of uncomplicated influenza, with and paralysis of some of the cranial nerves, espe- the exception of one case that had a bronchocially ocular and which otherwise correspended to pneumonia in connection with it. All the cases
ran a mild influenza course, with the one excep- features of this condition. Ankle clonus noted tion, with an apparent recovery in few days.
in a few cases. History of past nervous disturbances : One The temperature and pulse varied quite a litcase had had an attack of poliomyelitis when tle. As a general rule, the temperature did not eight years of age (the patient was 23 at the time rise very much, about 100 to 102, some cases of the encephalitis), one case gave a history of however showing a rise to 105 and 106 just before cerebrospinal meningitis of the epidemic form death. A number of cases showed a subnormal years before, most of the cases gave histories of temperature some time during the attack. nerve fatigue immediately preceding the attack The pulse in about 50 per cent of my cases, of encephalitis.
was comparatively slow and did not increase in Symptoms in order of their frequency:
frequency with the rise of temperature. Several
cases at the time of examination had a pulse as Parkinsonian face in practically all the cases.
low as 40, with temperature of 101 or 102. Lethargy in all except in two cases, who
Laboratory Findings. The spinal fluid was showed a wakeful delirium all through the dis- found practically negative in all the cases where a ease.
spinal fluid analysis had been made. The presSpasticity of the muscular system in all cases sure was very little, if at all, increased, the fluid except three.
appeared clear, the cell count showing a slight Ptosis, unilateral or bilateral, found in 20 increase, and in some cases globulin positive.
The bacteriology and culture of spinal fluid Speech disturbances in 18 cases.
was negative. Blood examinations showed leuEye divergence and ocular rigidity in 18 cases.
cocytes varying from 7,000 to about 10,000. Two
cases showed a leucocytosis up to 25,000. Blood Diplopia in 16 cases.
cultures were negative. Blood pressure about Headache of frontal variety in 14 cases.
normal, with several of the cases showing a lowRetention of urine in 13 cases.
ered blood pressure. Nystagmus in 11 cases.
Urinary findings were negative, with the exPupillary disturbances in 11 cases. Cervical rigidity, in a variable degree, mostly ception of a few cases where traces of albumin
. slight, found in 11 cases.
Mortality. Out of the forty-one cases examined Incontinence of urine and feces in 11 cases.
and classed as epidemic encephalitis, sixteen had Tremors in 10 cases. Tremors were more marked on touching the patient, although some
died up to the time of the compilation of this
paper. The prognosis in cases that lasted longer cases showed both rest and intentional tremors.
than a few weeks, as a rule, was favorable, as far Facial paralysis in 9 cases. This number does
as life was concerned, the majority of the cases not include cases where there was a paretic con
that died succumbing within one or two weeks dition, but only cases where facial paralysis was
from the onset of the disease. well marked, in the majority of cases unilateral.
Treatment. Purely symptomatic, with spinal Vomiting and nausea occurred in 7 cases, in
tapping affording transient relief. the early stages of the attack.
First. The disease appears to be more preTongue weakness, with inability to protrude, valent among adults than children. in 6 cases.
Second. Season of greatest incidence during Difficult swallowing in 6 cases.
the colder months of the year. Drooling, with excessive salivation in 4 cases. Third. Sexes about equally affected.
. The majority of cases complained of a dry con- Fourth. Influenza plays an important part as dition of the mouth.
a predisposing factor, as far as we can ascertain Sensory disturbances in 2 cases.
at the present time, from the history of the The reflexes were very inconstant, sometimes present cases and past epidemics. Fatigue, espeincreased, mostly normal, occasionally decreased. cially nerve fatigue, is a potent predisposing Babinski, and sometimes a Kernig, were aberrant factor.
Fifth. The clinical and pathological pictures that it will be impossible to speak of all of them, of the cases here are practically analogous with but we can discuss the most important. Before the cases reported abroad.
considering the problems it might be well to look Sixth. Strong clinical and pathological evi- at the question of the personnel of the officers as dence that epidemic encephalitis is distinct from found in the different cities of the State. classic poliomyelitis. This is also supported by As found today the health officer is one who is animal experiments undertaken abroad, where
chosen by reason of politics or as a means of inoculations with emulsions of nervous material, 'helping a young doctor to live until he acquires under conditions in which poliomyelitis has been enough practice to do so. The question of fitness transmitted to monkeys, failed to produce a para- by reason of special training is not thought of. lysis.
Therefore it is easy to see that many of the probSeventh. The causative factor is unknown. lems confronting us are not solved in any uniThe presumption of the influenzal virus, gaining
ing form way but are dependent upon the personal entrance through the nasopharynx, becoming view of the officer, controlled, however, by enactive upon a vitality lowered tissue, is, at least, vironment, politics or the desire to make capital as plausible as any advanced theory so far.
for future professional advancement. Eight. The prognosis, as far as life is .con-.
This is based primarily on the fact that in the cerned, is more favorable if the case lasts longer vastly larger percentage of the health officers of than a few weeks. Ultimate complete recovery
the State they are not paid a sufficient salary to is the rule rather than the exception.
make them independent in their action. While it Some very interesting experiments, published in the New York MEDICAL JOURNAL of May 3d, worth and in some instances probably more,
may be true that they are getting all they are 1919, by Strauss, Hershfeld and Loewe, tend to
under the present condition of things, it is also throw some light on the etiology and transmis
true that by just this very reason the public does sion of the disease. The authors report a series
not get the benefit that it is entitled to. This of experiments with monkeys. Inoculations with emulsions of human brain produced lesions char. brings us to the first problem, that I believe is acteristic of the lesions found in epidemic en
one of primary importance, namely, that of the
full paid, full time health officer whose time, cephalitis. The inoculation of the filtrate of the
energies, and capabilities should be devoted exmucous membrane of the nasopharynx of a patient not suffering from epidemic encephalitis clusively to the teaching of hygiene and comproduced no evidence of the disease in the pelling thorough and complete sanitation. The
trend of the times is marching to this proposition monkey. The inoculation of the washings of the nasopharynx of a case of epidemic encephalitis and there is no excuse for any locality in the
State not to have at least one man devote himself produced paralysis in the monkey accompanied by pleocytosis in the spinal fluid. A filterable
to this work exclusive of everything else. In the virus obtained from the mucous membrane of the larger cities where the taxable property is sufnasopharynx in a fatal case of epidemic encepha- ficient to maintain such an officer it requires no litis produced hemorrhagic encephalitis in the argument to emphasize the fact and under our monkey. This virus has been carried through a
present State laws the smaller communities can second generation.
join together, two or more, and employ such a man, and if the bill that is now in the Legis
lature becomes a law those counties containing THE LOCAL HEALTH OFFICER AND HIS only small villages can have a county medical ofPROBLEMS*
ficer. The handwriting is on the wall, the public E. W. WEIS, M. D.,
is aroused to the importance of this question, and
we as physicians ought to do everything in our LA SALLE, ILL.
power to help its advancement. The advantages The problems that confront the health officer
of a complete sanitary system are known and unin the State of Illinois are so many and varied
derstood by the public because of the wonderful *Read before the Public Health Section of the sixty-ninth
work done by the sanitarians in our army. It annual meeting of the Illinois State Medical Society at Peoria, May 21, 1919.
has been brought home to us with remarkable force the benefits derived by the incessant ens. The case may have been so mild as not to scientific activities in the camps and their imme- attract attention from either the family or school diate surroundings. Never before in history has nurse, and if from a carrier then many are placed there been such an aggregation of people with so under surveillance until the positive one is delittle percentage of morbidity and mortality. termined. Just this happened in Oglesby some When we contrast the results of the Spanish- months ago. A scholar with a mild case of scarAmerican war and the world war it speaks well latina, being anxious to continue in school, never for the advancement of sanitary science. This complained either at home or in school. He was new knowledge has come to the people and they cnly discovered when several weeks had elapsed are demanding greater and better protection. by his peeling skin. By then the school had been They have a right to it and they are going to set on fire and it required much action to conhave it, and the very insistence of their cry is re
trol the disease. flected daily in the press, public gatherings and "Am I my brother's keeper?” This text can in private demands.
furnish us quite a sermon in sanitation and it was I think I am competent to say that I know brought forcibly to mind in a very recent happen
I whereof I speak, for as director of the Hygienic ing. To the south of our city there is a small
, Institute of La Salle, Peru and Oglesby (which village of about 500 inhabitants that was badly was established by the late Mr. F. W. Matthies- ridden with smallpox, and had been for from six sen) and as Commissioner of Health of those to eight weeks. It had been erroneously diag. three cities I get it from three sides, and as I am nosed as chicken pox, and probably would have a full paid, full time health officer I can appre- been the focus for a general infection had not one ciate to its fullest extent the duty that devolves of the patients come to our town to consult a upon me in determining the solution of the many physician for a sore eye. The physician noticed
, many problems that confront us daily. While it that she was covered with peculiar looking posis true that the position I occupy is a rather tules. It required no expert to recognize it as a unique one in that I represent a corporation positive case of variola. She was immediately within three corporations, the work done by us removed to our Isolation Hospital and the State can be almost duplicated by any full-time health Board of Health notified. Officially our connecofficer in any community, at least sufficient for tion with the condition ceased right there, but their needs in the proper carrying out of sanitary being anxious for the protection of our own peorules and regulations and to prevent the further ple I made it my business to visit the village and spread of communicable diseases.
investigate for myself. A sad state of affairs The health officer to be successful must have was found to be existing, men, women and chilthe cordial if not enthusiastic support of every dren were walking the streets broken out in all physician in his town and at least the moral sup- stages of the disease; absolutely no precautions port of those in neighboring communities. Alone, had been taken. In one industry where some 300 even if backed up by the police power, he is im- men were employed it was found that some of potent in many directions, but by united team those who had the disease, but were not yet enwork wonderful results can be accomplished. tirely free from the contagion, were working This was exemplified in our recent epidemic of alongside of others, and among the employees influenza. The health authorities of many towns were a number who live in our town, and in other and cities in our neighborhood worked together neighboring cities, going back and forth daily. by advice and conferences. And it was agreed
And it was agreed y services were proffered to the local health authat the restrictive measures adopted should be thorities in the village to do the best that could uniform in all of them.
be until the state representative arrived. AnProbably the most difficult problem confront- other instance of similar character was in another ing the sanitarian is the ferreting out the original city at some little distance from us, where it case of cause of contagion either of typhoid, seemed that all of the precautions necessary to diphtheria or scarlet fever. If from an acute, prevent the further spread of contagion had not rather severe case it is easy, but if from a mild been taken, and where there was a proficient local one or from a carrier only, then the trouble thick- board. I visited the town, investigated condi
tions and urged a most thorough compliance with or more common communicable diseases. I rethe regulations. I think this a problem, for the fer to the control of venereal disease. Viewed reason that we can not expect the State author- from the economic side it is more destructive to ities, with a limited number of field men, to be health and well-being, and has shattered more everywhere, and it certainly should devolve upon minds than almost any other factor. I have rethe men who have charge of large communities cently heard a surgeon make the statement that to act in the capacity of the text of this para- 84 per cent of his operations were made necesgraph, I am my brother's keeper.
sary by the sequellæ of venereal disease. There is another problem that confronts the As you all know, the new law of the State Desanitarian that I believe should be definitely set- partment of Public Health makes it incumbent tled and I trust that there will be sufficient dis- upon physicians to immediately report every case cussion from every query to finally settle it. I
to the local health officer. Where he does so by refer to fumigation. We all know that fumiga- code number he assumes responsibility for the tion as it is practiced today is a farce, that most correct and proper care of that case, to prevent its of the fumigators that are in use are simply further spread. In this report he must state the for the purpose of camouflaging the public, and possible as well as the probable source of infecfor commercial purposes. Fumigating cans and
tion. In larger communities I am safe in saying candles are inadequate, and I do not think in one- that this source may be readily surmised but in tenth of the cases where they are used that actual
smaller communities, where segregated districts benefit results except psychologically, and if it
are eliminated, there is unanimity that the source were used in adequate quantities the price would is the common street walker. While it is easy be almost prohibitive, although I understand that enough to control so far as further infection is permanganate has had a great fall. The public concerned, the patient who comes to the doctor here in the west seems to demand fumigation or the druggist it is not so easy to control the simply because that is what they have always been source of the infection. How are we going to taught, and the health officer as a rule has not got deal with this problem? I have given this matter backbone enough to insist that a thorough scrub
much thought and have finally come to the conbing and a wiping down of the walls, with plenty clusion that about the only way will be to coof sunshine and fresh air, with the possible use operate with the Federal Government in its pubof a disinfecting solution, and a thorough boil. licity scheme by whatever method to adopt posing of all cloths of contact is sufficient. I have sibly the following: been informed that in the East, New York, Bos- After the subject has been brought to the atton and other places, they have quit fumigating tention of our communities as it soon will be by altogether, and so far as I can learn the results moving picture films, publications, pamphlets are the same. If this is true, why subject our and other means, so that the public will be pretowns, cities and school boards to the unnecessary pared to understand its significance, my plan is expense of purchasing these materials, with the to publish in the local press the number of cases added expense of employing men to apply them. reported and giving as the source that mentionea I would like a general expression upon this sub- in the report. I am inclined to the belief that ject and I hope that you will give it. This is a this publication will in a very short time drive problem that we are confronted with continuously every unescorted woman off of the streets at and will be more and more. As you know, variola night, for it will allow of only one inference, that is rather prevalent and this problem will con- they possibly and more than probably are the front each sanitary officer in every community in
source of infection. Decent women would not which it is found.
dare to be seen for fear of being classed erronAnd now we are confronted with an entirely cously, and it would be a common matter for new problem, one that will tax our ingenuity for speculation that the others are the guilty ones. its proper handling, but solved the problem must What would be your scheme? be for its importance is so great when we con
DISCUSSION sider that its victims are more numerous and its
DR. A. L. MANN (Elgin): Dr. Weis has presented results farther reaching than any of the ordinary the fundamental principles of the problem so char