Case History 2
Chapter 5 & 6
Back then, New York grew comparatively faster than other cities, it flourished to what it is today.

Iconic New Yorker E B White wrote that New York should have “destroyed itself long ago, from panic or fire or rioting. It should have perished of hunger when food lines failed for a few days. It should have been wiped out by a plague starting in its slums…. ” That never happened, the city triumphed to adapt and survive each trial.

As the American world metamorphosised, New York would evolve from the Victorian Age to the the Progressive Era. It became an inspiration. More than 40% of the population was of European descent. By the 1918, NYC was too, caught up in the Great War, and it had replaced London as the financial world hub, replaced Boston as the publishing capital, and replaced Paris department stores.

Neurology first leaped to world-wide attention with the astounding case of Phineas Cage in 1848. He was a rail road worker who survived a “freak accident” where an accidental explosion sent a metal iron rod through his head, it entered and shattered his jaw, passed behind his eye, and pierced the above of his skull, then the three and a half feet rod landed several feet from him. Inspite of all this he was able to walk, talk and even stood up! He was left with a marked change in his personality.

This case study gave physicians an idea as to which parts of the brain control which functions.

If we consider Cage’s to be the very first case, neurology was taught through the aftermath of the Civil War. Survivors of the Civil War also called it, the “soldier’s heart.”

This is all because neurology was growing as a specialty field in Europe wheras it lagged in the Americas. In fact, the early twentieth century neurology was referred to as neuro-psychiatry. It saw the mind and brain as one important entity but the brain would soon change to be seen as the grey matter surrounding the central system of any animal and the mind would be the center of emotions and thought processes that were distinct to humans. Other than the war wounds, the improvements made to the radiology and the image technology was another reason. Up until this point, the brain was viewed as something mysterious and unseen.

As one observer noted, “The X-ray threatened to expose the two holiest sanctums of the human body—the sex organs and the brain—and the process demystified both.”

After Thomas Edison invented the lightbulb, he also attempted one of the early versions of the X-ray machine, and Clarence Dally, his closest assistant, held the images with his left hand. Dally would eventually suffer from the burns and the hair loss, then his fingers and his left hand had to be amputated. The burns and infections still did spread and he ultimately had lost both of his arms. A disraught Edison had decided to abandon the project altogether.

This is how a lost finger and an amputated hand became the embelm of a radiologist.

Certainity favoured neurology.

During Dr Tilney’s time, these two would be seen as severed from one another and the brain and mind would never be related to one another ever again. In the 1920s, the dual force of neuro-psychiatry would prove to be essential. When encephalitis lethargica struck, physicians were confronted with a disease of the brain that wholly affected the mind.

In the 1920s, it would be required a necessity to place the two entities together as the disease encephalitis lethargica would confront physicians with both.


Dr. Frederick Tilney

He saw medicine differently, he saw it as considering the unknown.

He was on his way to see a new patient that morning, and her name was Ruth.

The doctor graduated medical school as valedictorian and travelled to Berlin to study neurology, this makes sense as at the time Berlin and Vienna were the neurological centers of the world. Germany’s labs were considered superior and in Vienna, neurology and psychiatry had attracted mass atention, and Tilney’s work left an impresion so much so that the idea itself would last more than a decade. When Tilney had returned to New York, he taught at Columbia University and in 1920 he would join the newly founded Neurological Institute. He was part of the major transformation of American medicine. America’s medical teaching was considered far inferior to Europe, and the focus was on the general practitioner and the body as a whole. Obtaining a degree back then was easy; future physicians were educated through apprenticeships and medical schooling was vague. This resulted in the emergence of odd medical practices with a long list of herbal tonics as the establishment of pure medical science by “quacks.”

In the twentieth century, at the height of the Progressive Era, medicine evolved into their respective medical specialties.

As Tilney lifted his feet off each step to Ruth’s home, he rang her doorbell. He removed his hat, pulled off his gloves and clung tightly onto his bag full of instruments and medications. The scene of the body was left grotesque. Ruth’s mouth dropped open, saliva ran down her chin, her hands clenched. She was clearly shuddering and shaking. It was clear that there was no paralysis.

Dr Tilney had asked her to blink her eyes or squeeze his hand. He asked her whether she could smell the pungent odours or hear his voice, she could but could not respond. When Tilney examined her limbs by bending it, tremors would begin right after the response. Her body behaved as though she was a puppet. The tremors were so bad that it shook not just her body but the bed as well.

To top off his case study, he inquired about the family history, Ruth’s eating habits, how many cups of coffee she had in a day, if she had alcohol and if she had undertook any excercise. He also followed up with further testing – the blood work was normal, the Wasserman test was negative, her spinal fluid was clear.

Everything but the girl herself appeared normal. Tilney’s case histories covered as much as possible of the patient’s life. Since Tilney’s handwriting, like most physicians’, was hurried and illegible, he often typed up his cases, and his typed files answered the usual questions.

Character of Birth: Premature or late, breach or complications? Status of Birth: Color of infant, weight and size of infant?
Diseases: All of the usual diseases, blows to the head, malaria, abnormal crying, eccentricities, conduct, poisoning, sleepwalking?

For treatments, he prescribed sponge baths to control fever, high colonies given daily to flush the system of any germs, and frequent lumbar punctures. In cases of insomnia, barbiturates were prescribed.

In Ruth’s case, she remained in a deep sleep and could not be roused. Tilney was at a loss—here was a patient who looked to be in a coma, but wasn’t. A patient who appeared paralyzed, but could be moved, bent, and changed into different positions like a doll. A patient who showed no response whatsoever to light, sound, touch, or smell, but could react when told to blink or squeeze a hand. Somehow that made it worse. There was not even the comfort that Ruth was unaware or oblivious to what was happening to her. Ruth was truly imprisoned in her own body, a child, palms pressed against the window, looking through the glass.

Finally, standing just beyond Ruth’s bedside, Tilney quietly told the girl’s parents that there was nothing else to be done.

He had performed every possible test; there simply were no answers.

Ruth seemed to fall away from their reach, deeper and deeper into her own closed world like a face disappearing beneath the surface of water.

Tilney apologized and in quiet tones told Ruth’s parents that she would never recover.

When Tilney turned and looked back at the sleeping girl, tears were running down her cheeks. A few days later, as Tilney had known it would, Ruth’s temperature rose to 107 degrees, her pulse raced as high as 170 beats per minute, and she died.

Chapter 6

European physicians could only do one thing at the advent of this rapidly spreading disease: pass along the dire news. This time it was for the worst. Their microbial opponent was shifting, changing and evolving with every brain affected.

Dr Tilney has treated other high profile people; Helen Keller, Henry P Davison.
He also treated the two best known victims of the epidemic during the 1920s; and these two cases would lead to the financial contributions of this disease. One patient survived but the later didn’t. Tilney was becoming one of the country’s experts on epidemic encephalitis. But what he did not yet understand about this disease was that death wasn’t the worst fate. Dying of encephalitis lethargica would not prove to be the tragedy; surviving it would.

The Matheson Vaccine Trials

A wealthy businessman who inherited a vast fortune was diagnosed with EL during the epidemic, his name was Wiliam J Matheson. He financed research that would help find a cure for EL. In the beginning of 1927, he donated $10,000 annually to a “commission” which was located at Columbia University in New York. It was ‘The Matheson Commission for the Study of Endemic Encephalitis.’ After Matheson’s death in 1930, his heirs funded the comission up until 1932. It lasted till 1940, using others donations.

A female neurologist with an expertise in bacteriology named Josephine B Neal, had been appointed to direct the survey of literature on EL. Matheson believed that this commission would find a cure for EL in 2 years and then proceed to find a cure for polio. The commission produced three significant reports on the disease; 1929, 1932, and 1939 which was all published by Columbia University Press. Neal did edit in what now may be considered a fourth and final report in 1942.

These studies however, are easy to dismiss simply due to the fact that the methods contained no controls to assure that the vaccines had contained any of the bacterial/viral material and therefore no definitive evidence was proclaimed.

All the trials do is attribute to providing a testimony as to how the trials wre conducted in that standards of time biologically speaking. It maybe useful from a historical perspective.

The Matheson’s Commission’s vaccine however, were guided by two main theories either that EL was a form of herpes or that it was a focal infection resulting from a neurotropic form of Streptococcus viridans.

Chapter 7

On February 4, 1919, Tilney prepared for the address he would give as the retiring president of the New York Neurological Society. As he did so, encephalitis lethargica, the disease the medical community was still loath to call epidemic, was spreading rapidly. In New York, health officials bickered over whether or not the disease was accurately diagnosed, much less epidemic. So far, the disease had not even been mentioned in the newspapers. The first article would appear in the New York Times in March of that year with a warning from the health department about a new, unexplained disease from Europe beginning to spread.

The war had provided the first opportunity encephalitis lethargica had to crawl across the world with little notice from the medical community. And by 1918, the pandemic flu had given it the second opportunity, stealing worldwide attention, infecting and killing millions. Epidemic encephalitis moved with the flu, almost like a parasite to a host, often attacking many of the same victims, receiving very little notice at all.

By the time Tilney retired from the New York Neurological Society and prepared his closing remarks, the city of New York had lost well over 100,000 people to the pandemic flu. Doctors had fought a losing battle against influenza, but Tilney and other neurologists saw opportunity in encephalitis lethargica. A fellow neurologist in New York wrote about the epidemic, “There has been no occurrence in the field of neurology that has been as illuminating as encephalitis, in that its manifestations may ape practically every neurological entity.”

With more cases appearing each week, and Tilney’s tireless work at improving the Department of Neurology, he was more convinced than ever that New York itself was positioned to lead the world in encephalitis research. Europe was still in chaos after the war, and all of the destruction had slowed intellectual pursuits, narrowing Europe’s scientific lead over America. What’s more, World War I had made the United States a world power, and the flu pandemic had made American medicine a respected force of both public health control and laboratory research.

Cases of encephalitis lethargica were now appearing not only in Austria, France, and England, but in Russia, Italy, and parts of Africa and Asia. It was as if no corner of the world remained untouched by this strange disease. In the United States, cases were surfacing in major cities all over the East, extending as far south as Texas and as far west as Illinois, and the number of patients was about to triple. But it was New York that saw the highest number of cases, and it was New York that would become the focal point of research.

Another factor made the city ideal to sit at the helm of American medicine. Unlike in many other cities, New York’s medical community had a close association with its public health institutions. Epidemiologists would have little chance against this disease without the tireless efforts of New York’s Department of Health.

Epidemics of cholera and diphtheria in the 1890s put the health department in a role of greater importance and gave recognition to its newly formed Division of Pathology, Bacteriology and Disinfection. The bacteriological laboratory would thrust New York into the spotlight of world medicine and public health. That was a remarkable feat—there were the Johns Hopkins labs, Mayo Clinic, Pasteur Institute in Paris, Lister Institute in London, the clinics in Berlin and Vienna … and New York’s municipal health department lab.

When it came to infectious diseases, community health overruled individual rights. Physicians as well as citizens had a legal responsibility to report any cases of infectious disease; individuals could be isolated and quarantined in their homes; even landlords were responsible for not allowing a sick tenant to leave or move without consent of the health department.

Interestingly, the 1916 outbreak of polio afflicted nine thousand people and went down in history as the most devastating polio epidemic in New York. By the time epidemic encephalitis would suddenly and inexplicably disappear, it would infect at least five thousand New Yorkers, and it would not go down in history as anything at all.

New York City and its public health department had been dealt a series of blows. Still, in 1918, the New York Times reported that “the Health Department of the City of New York stands as a model of municipal health service in this country, and has been recognized abroad.”

The organized and well-run public health offices were thus able to supply the Neurological Institute with an epidemiological gold mine—patient records, statistics, outbreaks. There could not be a better system for investigating an outbreak of disease than to have all of those separate pieces working together. The health department went into the neighborhoods and recorded cases; the public health laboratories diagnosed cases and studied tissue samples; the New York Academy of Medicine provided an endless source of articles published throughout the world; and the Neurological Institute had the funding, space, and talent to conduct brain studies. Certainly, with that kind of combined effort, doctors hoped the mystery of this disease could be solved in the coming decade.

Sources;

ASLEEP
THE FORGOTTEN EPIDEMIC THAT REMAINS ONE OF MEDICINE’S GREATEST MYSTERIES
Chapter 1- Chapter 7

Encephalitis Lethargica
During and After the Epidemic

Chapter 3 Epidemiology of Encephalitis Lethargica

Chapter 5 Post-Endemic Period Encephalitis Lethargica
Chapter 9 Etiology