myelitis and cerebro-spinal fever tends to confirm our belief in the truth of this assumption. All three maladies are potentially infectious, yet sporadically and sparsely distributed at the most. The Sheffield outbreak with 301 cases was investigated with the greatest minuteness; yet there was found nothing to indicate a relation of one case to another or any significant grouping. As it has been vividly put by one authority." It was as if a demon in the sky had shot at Sheffield with a scatter-gun. The discovery of the role of the carrier has explained the apparent anomalies of incidence in the two analogous diseases. It is at least likely that in the case of encephalitis the same will occur. 24. Diagnosis. In the 20th paragraph of this chapter a list is given of those maladies, most of them cerebral in nature, which have been or are likely to be confused with encephalitis. The problem of the diagnosis of this disease in its early or acute phase is very different from that of its identification when later manifestations develop. As regards the former, any pyrexial illness without obvious local or general cause, especially if it occurs in regions and at times when encephalitis is prevalent, should cause the attending physician to ask himself the question : "Is this perhaps a case of epidemic encephalitis? If in addition to some degree of fever there be drowsiness or stupor, or alternatively delirium, or an alternation of these two, a diagnosis of encephalitis lethargica is indicated. If, further, there be double vision or obviously irregular working of the muscles of eyes and face, the diagnosis becomes probable. As has been repeatedly said, cases shade off from those of such high virulence that they can almost be described as fulminating, to mere temporary and scarcely noticeable aberrations of health. Naturally it is these slight cases that are most difficult to diagnose contemporaneously and are most liable to be overlooked. True, these mild cases would appear to be those that are least likely to prove grave either immediately or ultimately, but even very mild attacks are occasionally followed by Parkinsonian symptoms leading to gradual disablement and ultimate death. The diagnosis of the late phase, when it does supervene, is a problem of quite another order. After a long, sometimes very long, latent period, during which the patient may seem to his associates to be quite well, or at most to evince some mild eccentricities of conduct or an unwonted slowness in thought, speech and action generally, a very insidious process of deterioration sets in. The symptoms at this stage may be so evasive and so slight that even the most experienced and observant of medical men may overlook them; but as the malady progresses, its outward semblance becomes ever more and more typical, so that ultimately on entering a sickroom or a hospital ward where there is a case of encephalitis, a confident diagnosis can often be made at a glance. The picture of the sufferer from late encephalitis in the Parkinsonian phase is quite unlike any other in the whole gallery of disease. 25. Prognosis. For diseases such as enteric fever and small pox it is possible to give a case-mortality rate with fair accuracy. That rate may and indeed does vary in successive epidemics; but at least the facts can be presented and numerically stated with a close approach to truth. With encephalitis lethargica it is for obvious reasons far otherwise. In a considerable or even large, but not accurately ascertainable, proportion of the cases, the illness is so mild as scarcely to excite suspicion of its real nature. Indeed it may be said that cases manifest an unbroken series from those that are virulent and rapidly fatal, down through the moderate, to the trivial and transient. The proof of this is the number of those who suffer from severely incapacitating or even fatal symptoms in the later stage of the illness, who were only mildly affected in the acute stage; so mildly indeed that it is only by groping in memory that the patient or his relatives can recall the early stage of the malady. Admitting, then, that any figures that may be given must be at best only approximately correct. it may be estimated that out of a hundred. persons who suffer from a well-defined attack of this disease, about twenty-five to thirty on an average die during the acute attack. Of those who survive the initial illness, about 20 to 25 per cent. make a good and apparently a permanent recovery; while the remainder, almost one-half of the whole, subsequently manifest some disability, paralysis, tremor, apathy or character change, which varies in degree but is apt to be progressive and at length completely incapacitating. The case-mortality in this as in other diseases has varied according to the time and place of the outbreak. In England and Wales in 1919, 541 cases were notified, and more than one-half of these were fatal.* The case-mortality varies also with the average age of the patients. It has been seen that children and adolescents between the ages of ten and twenty are most prone to attack; but it is among those over thirty years of age that the case-mortality is highest. As a general rule it seems that, as might have been expected, the cases which are most severe at the time of onset are those that are more apt to develop disabling features at a later date. But this rule is not absolute, for, as has been stated, a number of cases which proved severe and intractable in the later stages were found to have been almost insignificant at what may be termed the acute stage. As to those cases which develop Parkinsonian symptoms a long time, it may be months, after the onset of the disease, the prognosis as regards recovery is not good, indeed is so grave that it may be regarded as almost hopeless; on the other hand, it has been noted that when the Parkinsonism is of comparatively early onset the outlook is somewhat more hopeful, as quite a number of complete recoveries after a condition of early Parkinsonism have been recorded. As to the probability of death occurring during the acute phase of the disease, there is agreement that those cases whose symptoms are mainly general and of a severe type are more likely to be fatal than those In the Glasgow outbreak of 1923, the mortality rate in the acute stage was less than 10 per cent. in which the predominant symptoms, even if marked, are local rather than general. 26. Treatment.-There is no specific treatment for this affection. So soon as a diagnosis has been made, the patient should be put to bed, if not already there, and the case should be notified. From what has been said as to the low infectivity of the disease, indicated by the rarity of its occurrence otherwise than as single sporadic cases, strict isolation is not necessary. On the other hand, since, theoretically, the element of possible infection cannot be entirely eliminated, no one, save only those required for his attendance, should be in close contact with the patient. In the sickroom the most wholesome æration that circumstances permit should be secured as being desirable for the welfare of the patient and likely to reduce to the vanishing point any risk of infection to others. In the vast majority of cases early removal to hospital, if feasible, should be arranged, because very exceptionally will the resources of the house and household be adequate to cope with the difficulties of nursing and control that a case of this nature implies. Trained nursing will be advantageous, if not, indeed, indispensable. Even in restless and wakeful cases, hypnotics, especially morphia, are contraindicated. Urotropine and hexamine have been given, but should be administered with caution. The hope that benefit may accrue from their action seems to be based on the experience of good effects from their use in cases of poliomyelitis. Any inmates of the house in which the case has occurred who suffer from any disorder of throat or nose should be carefully examined and kept under supervision. After the death or recovery of the patient or after his removal to hospital, the house, and especially the sick room, should be effectively cleaned and aired. But whatever be the nature of the infecting organism, it is in the highest degree unlikely that it will survive for even a short time after removal from its host. It is after the termination of the acute stage that treatment undertaken in the hope of staving off or of minimising either the risk or the severity of later manifestations is perhaps most propitious. Any measure likely to tend to eradicate surviving organisms from the blood or tissues, to enhance the natural resistant powers of the patient, and so to forestall and prevent the later and malign features of the disease, should be taken at this period. Regarding the treatment of the late phase when it does supervene it is difficult to make a useful statement. As no two cases are alike the treatment must be appropriately varied. The outlook is grave in every case, but for a number, some degree of arrest or even of amelioration may be secured. This ray of hope is brightest in those cases whose main feature is some perversion of character. For these something, even in certain cases a good deal, may be done. It requires, on the part of the physician, imagination and initiative, forbearance and compassion, and a cheerful and invincible pertinacity. On the part of nurses it needs a gentleness and self-control no less sublime. No illness requires of doctors and nurses more patience or self-denial than this. 27. Relation to Insanity.-With regard to those cases of late encephalitis which display gross mental aberrations or perversions of conduct, the question is frequently asked whether the patient could or should be certified as insane. Various opinions have been expressed upon this point with regard to the less aberrant cases, and it has been pointed out that thought, in such patients, if sluggish, is sometimes shrewd, and that periods of relative if not absolute clearness of mind alternate with periods when mental processes seem dull. With regard to the grosser cases there is sometimes no doubt that they fall into the category of the insane, but with these again there arises the question of expediency. Certification of lunacy, with consequent removal to an asylum, might be by no means the best thing for the patient, and might prejudice what little hope of recovery may still exist. Thus this problem is hedged about with difficulties. 28. Administrative Control generally.-Notification of the disease to the medical officer of health of the area is now universally required throughout Great Britain. For reasons of general domestic advantage as well as for the welfare of the patient, removal to hospital is desirable in almost all cases. The risk of infecting others of the household is very low, and by commonsense precautions of aeration and common cleanliness it can be reduced to the negligible. Beyond these obvious and simple measures our present knowledge does not allow us to proceed. The grievous and pressing problem of the suitable disposal of patients suffering from late encephalitis in grave degree has already been referred to. Only in institutions can such cases be suitably treated and controlled, and even there their presence causes a great tax upon the staff. 29. Action by the Scottish Board of Health.-Encephalitis lethargica was first recognised and described in Scotland in April, 1918. Only a few cases were recorded in that year. In June, 1919, the Local Government Board for Scotland sent to all medical officers of health copies of a report regarding encephalitis lethargica which had been made by members of the medical staff of the English Local Government Board in collaboration with the Medical Research Council. In March of the following year (1920) a memorandum was sent to medical officers of health in which problems of diagnosis were specifically referred to. In the circular which accompanied this memorandum it was suggested that intimation of any suspected case should be made by the attending practitioner to the medical officer of health, and that the latter might provide all available facilities towards confirmation of diagnosis, treatment, and any necessary isolation. In May, 1921, a further circular on the subject was issued directing the attention of medical officers of health to the latest information regarding the disease. At the same time the laboratory facilities that existed for the confirmation of the diagnosis of the disease were set forth. In November, 1925, it was decided to make encephalitis lethargica notifiable throughout Scotland as from January 1st, 1926; and in December, 1925, regulations were issued to that effect, along with an explanatory circular. On 4th March, 1926, a conference was held in order to discuss the problem of the disposal, control and treatment, institutional or otherwise, of the cases of late encephalitis, of which the Department had received distressing reports from many parts of Scotland, and in which, owing either to impairment of the patient's bodily health, perversion of habit or conduct, or actual disorder of his mind, his parents or guardians could no longer provide the necessary tendance or exercise the necessary control. At this meeting also there was considered an offer from the parish council of Glasgow to provide accommodation for about 50 cases of late encephalitis-25 beds for each sex-in their hospital at Stobhill, Glasgow. The conference, which was attended by representatives of local authorities and of the parish council of Glasgow, agreed that the disposal of cases of the disease in the acute stage would best be regarded as remaining the province of the Infectious Diseases Hospitals. The treatment of cases in the late phase, being sometimes required for extended periods, presented a problem of its own. A general feeling was expressed that such cases should remain the responsibility of the local authority, except where there was such definite mental aberration as to require care and treatment in a mental hospital. The offer of the parish council of Glasgow was regarded with favour. The question of terms was considered, and a provisional sum of seven shillings per patient per day was regarded as suitable. It was arranged that all applications for admission to Stobhill were to be submitted in schedule form through the Department, and a schedule, of which a copy is reproduced in Appendix XXI, was prepared for this purpose after consultation with Dr. Ivy Mackenzie, Dr. M. K. Anderson, Dr. A. S. M. Macgregor and others. A circular embodying these proposals and views was issued on 13th August, 1926, to all local authorities and medical officers of health, along with a sample of the schedule. Applications for admission were soon being received in great numbers. On 31st December, 1926, there were in Stobhill Hospital 31 male and 25 female cases of late encephalitis, admitted according to the arrangements above made, and at the instance of local authorities; while there were in addition 56 male and 63 female cases of similar nature admitted at the instance of the parish council. By this time the applications, especially as regards male patients, were greatly in excess of the accommodation available, so that there was already a considerable waiting list. This is steadily tending to increase, until recently the list of suitable cases awaiting admission to Stobhill was 92 |