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carry on a fair conversation under normal condi. tions. She is restless, lacks power of decision, has no will, no tenacity or power of concentration and will always be carried by any will stronger than her own. She could be trained from an early age to do one thing well, thus avoiding the economic pressure which she always meets in later life. Without special early training she cannot be economically independent and therefore drifts into prostitution where she can earn food and a bed.

It is my opinion that until Michigan has adequate institutions for housing and training the feebleminded, the problem of venereal prostitutes will continue to grow worse and venereal diseases will continue to increase in all classes of society.

AT WORK IN MICHIGAN. The Menace of the Feebleminded Prostitute and

How It Must Be Met. (By Katherine Ostrander, Director.) Up to the date of August 15, there have been 675 women patients admitted for venereal treatment throughout the State. Of these 391 (385 of whom are acknowledged and unacknowledged prostitutes) )have been discharged, no longer in an infectious state, leaving 284 women now under treatment,

Of these discharged cases, 20 are women who were recommended as being in need of care in the Michigan Home and Training School at Lapeer, but could 'not be taken because of lack of room in that institution. Sixty of them were diagnosed as retarded mentally but not to a degree making institutional care necessary. Thus, one-fifth of our discharged cases are subnormal mentally, some of them imbeciles. These high-grade morons are the most difficult cases to handle as they are not capable of deciding right and wrong, have no will-power and are led by any stronger will. They are often physically attractive and appear normal.

A great effort is being made to give these discharged girls and women every opportunity to live normal, well-balanced lives, special emphasis being laid on finding them congenial employment and lodging. To do this, it is sometimes necessary to take a girl out of her home environment entirely and place her with strangers who are interested in her, or with relatives.

Of the 391 discharged, one per cent. of seven cases have been returned to the hospitals reinfected. Knowing that a patient can reinfect herself through the natural course of the disease or by not taking treatments regularly, we cannot say how many of these cases are new infections. All but one of them are feebleminded.

The most difficult of all social problems is the high grade feebleminded person. She looks normal, is not usually physically disfigured, and is able to

During January the following articles have been accepted by the Council on Pharmacy and Chemistry for inclusion with New, and Nonofficial Remedies : Dermatological Research Laboratories:

Neoarsenobenzol. Guiseppe W. Guidi:

Merck and Co.:

Digitan Tablets, 1% grains,

Quinine Ethyl Carbonate-Merck.
Monsanto Chemical Works:

Chloramine-T, Monsanto.

Unsuccessful Attempts to Transmit Influenza Experimentally.—Two extensive attempts have been made under the auspices of the U. S. Public Health Service and the U. S. Navy to transmit influenza experimentally. Inoculations were made of pure cultures of the influenza bacillus, of secretions of the upper air passages in the early stages of influenza, and of blood from typical cases of influenza, and other methods of transmitting the disease were tried. In no case was influenza developed. (Jour. A.M.A., Jan. 25, 1919, p. 281).

Michigan State Medical Society Meeting

To Be Held

In Detroit, May 21-22, 1919

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Original Articles

eye closed, felt tired and dull. En route home

seemed dazed at the Station in Cincinnati and ENCEPHALITIS LETHARGICA.

was sent to hospital by the Red Cross. ReELMER W. SCHNOOR, M.D.

mained in the hospital one day and was disGRAND RAPIDS, MICH,

charged seemingly improved. Walked to street This quite obscure and mysterious disease car, which he boarded to depot; took train for has been variously termed: "a new disease," "a

Grand Rapids, his home, and arrived the mornnew syndrome,” acute epidemic encephalitis, · ing of January 28. Staggered into home and epidemic -stupor, nona, Heine-Medin disease,

shocked mother, seemed quite dazed, disinterepidemic encephalo-myelitis and sporadic polio- ested and giddy. Toward evening became deencephalitis.

lirious and trembling of whole body developed. Encephalitis lethargica is an infectious in

Dr. N. (the second case of this report) was flammatory disease of unknown etiology, char

called and found patient had a temperature of acterized by specific manifestations arising in

100 and talkative. January 31st I saw the pathe central nervous system, of which the most

tient in consultation with Dr. N. and patient frequent and pronounced characteristics are: gave evidence of quite profound stupor but general asthenia, progressive lethargy and

could be aroused and would answer a few quescranial nerve palsies.

tions in a droll manner, great effort present to History.Von Economo at the April, 1917,

raise eyelids and an internal strabismus evident meeting of the Viennese Society of Psychiatry

with marked congestion of retinal vessels but introduced the present common accepted term,

no evident hemorrhages. Distinct rigidity of lethargic encephalitis.

neck present, as also suggestive Kernig. Tache Professor A. Netter at the Paris academie de

cerebral marked. February 1st I performed Medecine on May 7, 1918, expressed the view

a spinal puncture. The clear fluid exuded unthat the disease is a distinct entity and not a

der markedly increased pressure and on examform a polio-encephalitis and believed the

ination showed a normal count and the cell disease occurred at the end of the 17th century

present of lymphocyte type. Culture negative. and the beginning of the 18th in Germany. It

No albumen reaction and no film development occurred in upper Italy and Hungary in 1890

in specimens left in refrigerator for three days. when the pandemic of influenza of that era was

Wassermann reaction was negative. Centrideclining. Very suggestive cases occurred in

fuged sediment showed no tubercle bacilli. nearly all countries of Europe and in the United

Blood and urine were examined and found nor

mal. February 2nd, the right pupil was States in the spring of 1895. No doubt exists, that the disease occurred in Vienna in the win

smaller than the left and a distinct bilateral ter of 1916-17. Harris of London and Hall of ptosis. February 3rd, Asthenia marked, unable Sheffield called the attention of the British

to raise extremities and profuse sweating began Medical profession to the diseasc in March,

and has continued to date. Incontinence of 1918. Cases have recently been recognized in

urine commenced and lasted for ten days. Folthe United States.

lowing spinal puncture he was brighter for

three days and then passed into a stupor for CASE I. Male, age 18, seen service in Naval Reserve at Hampton Roads Naval Base. Jan

seven days and then gradually became brighter. uary 21st, a week before his return home, after

Opened eyes in a half way manner and paid atdischarge from navy, he noticed a "twisting"

tention to happenings about the room and talkof eyes and saw double, had to read with one

ed to his wife whom he previously had not

recognized. March 7th, was permitted out of *Read before Muskegon County Medical Society, March 21,

bed and at present, March 16th, his eves have



improved but the left ptosis remains and after 2nd to the 8th the pulse was 120 to 128, respiraprolonged focus of eyes on an object the left tion 22 to 28 after March 8th, pulse 84 to 100 eye converges. He sits listless and moves his and respiration 20 to 24. March 2nd to the jaws frequently as if chewing. He walks about 10th, had retention of urine, necessitating cathea little, slowly and somewhat uncertain. He terization. At all times took nourishment when does not venture to speak unless spoken to and aroused and offered to him and now has a vorararely smiles. Appetite is voracious and thirst cious appetite. Constipation present intense. Noise irritates patient intensely. throughout the course. Eye examination by Dr. Hearing seems to be very acute. From Feb- Camp revealed a mild neuro-retinitis. Later ruary

1st to the 14th carried a temperature Dr. Camp reported spinal fluid negative as well ranging from 99.4 to 103.4, pulse 112 to 136 as blood culture, and Wassermann reaction. and rather feeble at times and respiration 22 to Urine and blood examined by Dr. Northrop 28. Sleeps well but quite prolonged.

negative. CASE II. Dr. N. Physician, male, aged 41, CASE III. Male, age 68, February 17, comfirst saw case I on January 28 and was in at- plained of vague pains in back and felt tired. tendance four days--26 days later, Saturday, Five days later began to get drowsy and seemFebruary 22 seemed quite weary and surprised ingly weak. Seen by another physician but no that his vision was somewhat blurred and he diagnosis made. February 25th very stuporous saw double. This diplopia lasted two days but and hesitancy in speech noted, at times wide the blurred vision has continued to a degree awake and would wander about room. Febto date March 16th but is improving-weari- ruary 26th marked weakness of extremities and ness progressed but the doctor continued his pains in legs when I was called. Suggestion of

I practice for three days when he complained of left facial palsy and difficulty in speech. Febcardiac palpitation and consulted Dr. Northrop, ruary 28th speech more distinct, weakness and complained of extreme tiredness and seemed drowsiness marked, facial palsy distinct and dull and irritable. The following day, February rigidity of neck present. March 1st, stuporous, 26, felt weaker and drowsy and took to bed, slight temperature; arousable but unable to would speak with an effort to the immediate speak distinctly though an effort was made, members of his family, was quite indifferent but performed certain acts desired. March 5th and oblivious to surroundings. March 1st as- neck distinctly rigid with slight retraction and thenia more marked and trembling of body dysphagia present. Dysphagia continued for evident with pains in forearm and next day in six days and has improved. The period of the hip and legs which continued intermittently first four days during which the dysphagia was for a week. Sunday morning, March 1st, I saw pronounced, the patient had intervals of the ratient in consultation with Dr. Northrop Cheyne-Stokes respiration. Mentality brighter and diagnosed the case encephalitis lethargica and extremely restless and 'moaning at times and suggested spinal puncture. Later in the developed and continues. The patient had inafternoon further consul with Dr. Camp occur- continence of urine for a few days as also inred, who performed spinal puncture and took continence of stool. March 14th able to articublood culture. Two days later, March 4th, he late and answer questions with monosyllabic began to seem brighter, talked spontaneously words. Sits up unassisted but restlessness conthe next day and became very restless. This tinues. Urine faint trace of albumen, with restlessness was quite extreme for a period of mucin and few leucocytes and epithelial cells nine days and then began declining. With the present. Blood pressure 140. Eve examinadecline of restlessness the doctor has assumed tion by Dr. D. Emmett Welsh revealed swella rather euphorious state, being quite elated ing of nerve head, blurring of disc, marked over his improvement. Some difficulty in rais- venous engorgement and contraction ing the neck was experienced after the first terioles. week and gave evidence at my examination by a Etiology.--Von Wiesener, who studied Econsuggestion of distinct resistence on March 2nd. omo's fatal case, a girl of 14, cultured a diploProfuse perspiration became evident four days streptococcus but was unable to demonstrate the after onset and a miliarial eruption appeared on organism anywhere in nerve tissue in microMarch 3rd. Four days after onset an evening scopical preparations. Wilson reports negative

. rise in temperature 100.6 occurred but was bacteriological findings in tissues of his two normal next morning. After this it ranged from fatal cases and refuses to accept von Wiesen99 in the morning to 101.6 in the evening for er's diplo-streptococcus as an etiological factor. twelve days and then became normal. March McIntosh on behalf of the Medical Research

of ar

Committee of London Hospital and Hancock consisting of neuroglia cells of several kinds, and Pearse of the food branch of the Board's including large cells with voluminous eccentric Medical Department of London, investigated

nucleus and many fibrillary prolongations, lymfrom the view of possible food origin and con- phocytes and polynuclears. The foci appear cluded that neither on the bacteriological, nor sometimes to be altogether independent of on the epidemeological side could any direct or vascular infiltrations and might occur in the indirect evidence be obtained of an association nerve roots, as the hypoglossal, pneumogastric, of the illness with bacillus botulinus or with etc. (3) Lesions of the nerve cells which did food infection. The results of the preliminary not correspond with those usually seen in ininquiry pointed to a possibility that it might fantile paralysis. There was dissolution of the be one of the many forms of the disease or group

soi-disant, Nissl bodies, relative achromatosis, of diseases at present labeled "Heine-Medin”- reduction in volume of cellular body and numdisease, of which acute poliomyelitis was the ber of neuronphagia as described by Economo. commonest type. Picken believes the cases first (4) Foci of hemorrhage much more numerous regarded as botulism, to be polioencephalitis, an when microscopic examination was made. Hemaberrant form of acute anterior poliomyelitis orrhages remained circumscribed around walls and reported two cases. Breinl of Australia of small-vessels and red cells mingled with instates that pathological and experimental re- flammatory infiltration cells. The vessel walls search convinces him that the Australian “Mys- did not appear necrosed but sometimes a solu-, terious Disease” represented the identical virus tion of continuity of vessel wall could be seen. as that of acute poliomyelitis and clinically Buzzard's microscopic study of pathological presented a polioencephalitis. Marinesco and lesions showed the remarkable way in which the McIntosh concluded independently that enceph- vessels of the brain reacted in this inflammatory alitis lethargica in the 1918 outbreak was the process. Chief features are: (1) Perivascular same disease as described by von Economo of infiltrations, mainly with small round cells. Austria and Netter of France and was a dis- (2) Small capillary hemorrhages which suggest ease clinically distinct from analogous affec- a gradual oozing of blood, through damaged tions. Hamer of the Royal Society of Medicine walls of small veins or capillaries. (3) Throm. believes the epidemic merely part and parcel ‘bosis of small and middle sized vessels in difof a prevalence of influenza. During the last ferent stage of organization. (4) Ischemic ten years evidence has been collected clearly softenings presenting appearance of hemorshowing close association between outbreaks of rhagic infarction. (5) Subarachnoid hemorpoliomyelitis, polio-encephalitis, cerebro-spinal rhages and cellular infiltration of lepto-menmeningitis and prevalence of influenza. Noel inges. (6) General neuroglial proliferation. calls attention to the marked similarity of a (7) Chromatolysis and coagulation-necrosis in large number of case to typhus fever. Lethar

nerve cells. gic encephalitis occurs in all ages and about Box's case, an apoplectiform type of epidemic equally in sex, and most prevalent in winter encephalitis, suggested hemorrhage and at postand spring.

mortem, some of the lesions suggest hemorrhagic Pathology.—Marinesco, professor of Neurol- infarction rather than true extravasation and ogy at Bucharest has found disseminated mil- states it is conceivable that perivascular exudaiary or punctiform hemorrhages visible to naked tion might itself lead to vascular strangulation eye in the grey matter in neighborhood of floor or thrombosis. of 4th ventricle, the aqueduct of Sylvius and Symptoms.--The incubation period of this even the 3rd ventricle and also posterior part disease is variable and indefinite. The onset of pons and peduncles. Cerebral cortex show- in five of sixteen of Hall's cases was sudden, ed congestion of lepto-meninges. The first the rest gradual. A prodromal period, MacNalty segment of spinal cord same histological lesions states, commonly ranges from one to seven days as pons, bulb and peduncles. Microscopical but might be as protracted as three weeks durstudy of the above mentioned regions had dem- ing which occurred lethargy, headache, vertigo, onstrated existence of four kinds of lesions: giddiness and diplopia, as well as lassitude, (1) Infiltration of walls of small vessels, espec- fatigue, vomiting and diarrhea. The onset is ially the veins, consisting of lymphocytes and usually ingravescent especially in the type with plasma cells in the adventitia, disposed in sev- cranial nerve palsies which usually take some eral layers. The endothelium and filroblasts time to develop fully and may vary in extent might also take part in the inflammatory pro- from day to day. Fever occurs in the majority

(2) Foci of interstitial inflammation of cases often of low-grade type, other times


severe and prolonged and intermittent and re- turbances of the functions of the central nermittent in type. General asthenia gradually vous system but without localizing signs. (2) becomes pronounced with muscular pains and Types with nervous localizing signs: (a) affecoccasional twitchings. Cranial nerve palsies tion of 3rd pair of cranial nerves, (b) affections may be distinct. Ophthalmoplegia, external or of brain stem and bulb with localizing lesions internal may be distinct with ptosis symmetrical of other cranial nerves, (c) affections of the or asymmetrical, complete or incomplete. Paral- long tracts, pyramidal, prepyramidal and upysis of accommodation and corresponding in- coming afferent tracts, (d) ataxic types, (e) distinctness of vision or diplopia, Wilson found affections of cerebral cortex, (f) types indicata frequent and early symptom. Involvement ing some evidence of spinal cord involvement, of lower cranial nerves to a variable extent is (g) polyneuritic type. (3) Mild or abortive not uncommon; facies often expressionless; types with or without localizing signs in central obliteration of facial lines; palate, tongue, lar- nervous system. ynx and pharynx may have transient im- Course.-Of disease varies greatly in typical plication. Pupils may be contracted, dilated cases, it may end fatally in a few days or be and fixed or normal.

prolonged for weeks or months. Of the general symptoms, indifference, in- The stupor may last but two or three days or aptitude, oblivious to surroundings, drowsiness, often two to five weeks. I have been informed lethargy and stupor is in one degree or other by a member of Hospital Corps, Camp Custer a feature from the onset, occasionally the leth- of a suspected fatal case of encephalitis letharargy appears later in the disease. After a vari- gica being in a stupor for forty-seven days. Alable period, the stupor may be replaced by ex- tered mentality and cranial nerve palsy may treme restlessness alternating with apathy. One persist. Findlay reports one case with a right is impressed by the fact that the patient in the sided facial paralysis, ptosis of right upper eyelethargic state responds quite correctly when lid, left external squint and a general mental spoken to in word and act and takes nourish- apathy. ment as often as presented to him unless dys- Prognosis.—Buzzard states some cases recover rhagia is distinct. Speech may be affected and completely, others survive the acute stage but may be droll, slurred or rapid or may suggest carry with them in after life permanent defects an aphasia. Retention of urine may occur but due to the morbid process. A certain number usually incontinence is present at sometime as die of toxemia or hemorrhage in the acute ill

'so of feces. Hyperidrosis is pronounced and ness or from some complication. James records may be associated with a miliaria eruption. a mortality of from 15.8 to 20 per cent., 8 per

8 Tache cerebrale was pronounced in my first case. cent. under ten and 8 per cent. from ten to Distinct rigidity of neck muscles or only a re- nineteen. Economo's ratio of mortality was six sistance may be present associated with pain. of eleven cases. Netter, seven out of fifteen; A suggestive Kernig may be evident but Babin- Wilson two out of thirteen ; MacNalty collected ski, Brodzinski, Oppenheim, Gordon and Chad- 168 with 37 deaths; Findlay one of three. dock were negative in my cases. Delirious at- Diagnosis. The most common error in diag. tacks and Cheyne-Stokes breathing may occur, nosis is to attribute the condition to tuberculous especially if the medulla becomes involved mak- meningitis. The cardinal symptoms of lethargic ing prognosis most grave (Case 3). Constipa- encephalitis are asthenia, lethargy and cranial tion is present in most cases.

nerve palsies. Acute poliomyelitis is chiefly Vaidya found the average leucocyte count, a summer or autumnal disease while epidemic 7600 per c.mm. and relative cellular proportions stupor has been in evidence in winter and normal. An occasional higher count was ac- spring. counted for by a complication. Spinal fluid Prophylaxis. In conference with Dr. C. C. was clear in all cases, without coagulation on Slemons, Health Officer of Grand Rapids, it was standing but in two of my cases, showed in- thought best to institute the same preventative creased tension. Spinal fluid protein was never measures as in acute poliomyelitis. more than slightly increased. Cell count nor- Treatment.--With the etiological factor obmal or slightly increased and type of cell always scure no specific treatment is recommendable. lymphoid. Pothier found a definite pleocytosis Eliminative, hydrotherapeutic and hygienic of the lymphocytic type in cases at Camp Lee, measures are indicated as in any acute infecVirginia.

tious fever. Frequent change of position is Various types of the disease are classified by necessary to prevent hypostasis and decubitus. MacNalty. (1) A type displaying general dis- Spinal puncture relieves the intra-cranial ten

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