male and 9 female. In respect of a number of these the need for institutional treatment is very urgent. 30. The Outlook.-A malady of which from 10 to 20 per cent. of all the definite cases die during the acute stage, and of whom only one-third of the remainder make a complete and permanent recovery, is obviously a serious menace to the community. On the other hand, the incidence of encephalitis lethargica, even in 1924 when that was at its highest in this country, never exceeded the ratio of one case per 6,000 of the population. Had a disease of equal severity been even approximately as infectious as measles, the community would have been swept by a pestilence compared with which those of the middle ages would be insignificant. Fortunately, then, although the average degree is severe and the case-mortality high, the incidence in relation to the whole population is invariably low, and there is good reason to believe that during the last two years it has fallen markedly. Despite that diminution, new cases of Parkinsonism or other late manifestations in cases whose onset took place two or three years before are constantly coming to light. In view of their protracted and intractable nature, the problem of their disposal is an anxious and onerous one. 31. Authorities.-Many authorities have been consulted in the preparation of this survey. Among these may be especially mentioned the Report by the Ministry of Health on Encephalitis Lethargica, issued in 1922; that on the Sheffield outbreak of Encephalitis Lethargica that occurred in 1924, issued by the Medical Research Council in 1926; and the Monograph or Textbook by Professor A. J. Hall of the University of Sheffield, published in 1924. The last contains an admirable and exhaustive bibliography of the disease, extending to 75 pages. APPENDIX I. BRIEF DESCRIPTION OF CASES FROM THE CLINICAL POINT OF VIEW. Case 1. Typical Case in Initial Stage (so far as any case can be described as typical). A. L., aged 33, female, married. Illness began suddenly with symptoms of rigor, pain in the right shoulder, restlessness, sleeplessness and general twitching movements. On admission to hospital she was seen to be very ill. Temperature ranged from 101° to 103°. Jerky tremulous movements of the arms, not resembling chorea. There was also twitching of the face. Patient complained of headache but not of diplopia. There was no squint. She was very restless, constantly trying to get out of bed. She was highly delirious, but could always be recalled from the delirium for a time. The twitching movements gradually subsided. After administration of paraldehyde the patient slept and the delirium ceased. There was no evidence of lethargy. Case 2. Illustrating Early Parkinsonism. 991 C. U., aged 23, a carter. Illness began in June, 1924. It was diagnosed as encephalitis from the outset. Sequelæ were manifested early-within a month or two of the commencement of the illness. Patient was in hospital for two weeks in the first half-year of his illness, drowsiness being then the most marked symptom. He was visited for the purpose of this record about thirtytwo months after the onset of his illness. He lives in a house of two rooms occupied by six inmates. The household income is sufficient. The patient has a weakness of the left leg. His condition may be described as one of early Parkinsonism. There is no indication of mental disorder, and his cerebration is not notably slow. Nevertheless, he has a somewhat vacant expression. He leans forward as he sits, his head gradually drooping more and more. For a city dweller he speaks slowly. The case may be regarded as a fairly typical instance of the Parkinsonian picture in an early stage. Case 3. Case shewing Parkinsonian Symptoms with tendency to remission or amelioration. A. T., aged 21, motor-driver. Recent illness (from November, 1926). His malady was diagnosed correctly at the outset. He has had no institutional treatment. He lives in a lodging of one room with a widowed mother and three adult brothers. Apart from the number of the occupants, the home conditions are not good. His mother and brothers are at work, and he is alone in the house all day. About a month after his illness began he suffered from nervousness and undue excitability, exaggerated reflexes, tremors, snuffling, salivation and a stolid expression— in short, incipient Parkinsonism. Later, after a stay in the country, he was found to have made definite improvement. Except, perhaps, for some fixity of gaze, there was little sign of illness. His movements seemed normal. He expressed himself as feeling much better, though he added that he did not think that he was able to drive a car. It cannot of course be predicted with any confidence that this improvement will be maintained. Case 4. Typical Parkinsonian Case in Fairly Advanced Stage. L. C., female, aged 14. Illness began in March, 1923, and was at first mistaken for St. Vitus dance. Thereafter there were choreic movements, pyrexia, nocturnal delirium, diplopia, headache, and some degree of lethargy. She was in hospital for fully three months, and improved so that upon discharge, though not quite well, she was able to attend school. She continued to go to school until April, 1924, but latterly her attendance was irregular as she was very drowsy in the mornings. Soon after ceasing to attend school she began to drag her right foot. Stiffness gradually increased until by January, 1926, she could not rise from a chair without help. When visited she was found to be thin and pale with typically Parkinsonian expression. For the last year she has hardly spoken, and only to express her needs. Salivation is excessive. There is tremor of the right hand. The right hand is kept in a position of semi-flexion. There is considerable paresis, so that she can only walk with assistance. The right foot is flexed and inverted. She sits with her back bent in a crouching attitude. There is now no lethargy. She sleeps well by night but not by day. She occasionally displays irritability. Occasionally she reads a little, but for the most part she sits idle. It does not appear, however, that there is any marked impairment of memory or intellect. The domestic circumstances are not remarkable. There are three rooms and six inmates. The household income is not straitened. APPENDIX II. NOTES OF CASES ILLUSTRATING THE DOMESTIC OR Case 1. W. P., male, 11 years. This boy's illness commenced suddenly in March, 1921, when he was six, with sickness and mental excitement. He has been excitable and restless ever since. A definite diagnosis was made in 1926. He has been twice in the Sick Children's Hospital. He lives in a house of three rooms with grandmother, uncle and aunt. The household circumstances are fairly comfortable. Patient is now (December, 1926) quite beyond the control of his relatives. He is passionate and violent, given to screaming and kicking. He has struck his grandmother and his aunt. He molests other children. He has burnt underclothing, put household articles into the fire and up the chimney. He has undressed in a public park. Recently he disappeared for nine hours and returned without his new overcoat and hat, and could not account for their loss. He has no paralysis. His habits are clean. Usually very restless and excitable, but has intervals of quiet and depression. Wassermann test has twice been negative. He is pale, furtive in expression, and talks quickly and clearly in a loud excited voice. He is afraid of strange visitors, fearing that they may have come about his removal. When visited recently he took refuge under the bed, and on being dislodged from that retreat shut himself into the water-closet. He is quite beyond the management of grandmother, uncle and aunt; is a constant anxiety to them, a source of trouble to the police, and unsuitable for any ordinary hospital. Owing to his peculiarities, the authorities at Stobhill Hospital do not desire to admit him. His removal to an asylum for the insane has been suggested, but that also is clearly not a perfect solution of the problem. Case 2. A. W., male, 9 years. Has been before the local police court on charge of theft of money. The question arises whether he is mentally defective, and so suitable for admission to Baldovan or Larbert. Father unemployed. Household: parents and nine children. Five, including the patient, are under 14. Patient has caused much trouble by theft, assaults, and annoying children and adults. He is a menace to the district. Frequently been before the police court but not punished, on account of admitted mental incapacity. Household circumstances moderate. No poverty, but father unable to pay for institutional treatment. Boy quite beyond control. Was in Sick Children's Hospital, Glasgow, for over a year. Illness began in February, 1925, and was correctly diagnosed at the onset. Physical condition is good. It was reported in August, 1926, that the boy was in trouble almost daily, and that the police were pressing for action to be taken, as they regarded him as a menace to the public in the district. Removed to Stobhill 3rd September, escaped on 6th; found by police at Bishopbriggs. Escaped again on 7th and arrived home in Ayrshire on September 8th. Case 3. J. C., male, 14 years. Undersized. In fair physical health. Occasionally troublesome; sometimes wild. Has attempted to assault other boys with a hammer. Education fair. Lives with mother, stepfather and stepfather's daughter. Very troublesome at school; fights with other children and throws stones. Is beyond control at home. When in hospital he inflicted wounds upon the heads of two other patients. He had treatment in four institutions. Date of original illness doubtful. Notified June, 1924. First signs of late stage at end of 1925, when he began to be bad-tempered and violent." Case 4 (shewing a typical instance of a familiar problem).— M. Q., aged 24, miner. With his wife and two boys, aged three years and eighteen months respectively, he lives in a clean wellkept house of two rooms and a kitchen, two stairs up, in a new house in a city suburb. The illness began in July, 1924, with listlessness, weariness on exertion, and drowsiness. A diagnosis of encephalitis was made in May, 1925. He has had institutional treatment; indeed it was in a general hospital that the diagnosis was made. On visiting him in his home thirty months after the commencement of illness, he and his younger boy were found in bed. His wife, who works a little and who has to go out for supplies, and the elder boy were from home. The patient has been unable to do any work since September, 1925. He and his family are supported by the parish council. He said: We can do with what we get, but it is a struggle." He is able to walk about the house, but he has a peculiar stooping, shuffling gait, and shews tremors. There is little or no indication of mental impairment. His mind is not alert, but, given time, he answers 66 questions reasonably or even shrewdly. He has frequent headaches. His appetite is fairly good. He is not unduly sleepy now, though he remembers being so at the beginning of his illness. As he cannot look after the house, his wife cannot accept any regular employment. He desires readmission to hospital, partly in the hope that treatment may lead to improvement and partly that his wife, owing to his absence and by boarding-out the children, may be able to engage in regular work. Case 5. (Another unselected case, or selected only as exemplifying a common type.)-S. W., aged 22, was formerly a motor-driver. He lives in a somewhat congested part of a city in a house of many rooms. The household consists of his father, who is in regular and good employment, his mother, to a considerable degree an invalid, three sisters, all of whom are at work, and three brothers, of whom the patient is the eldest. The family are in comfortable circumstances. The patient's illness began, about February, 1925, with insidious and indefinite symptoms. At first his behaviour was ascribed to laziness. He was occasionally sleepy. He began to be slow in all his movements and was dismissed from his work on that ground. A year after the onset of illness, namely in February, 1926, a diagnosis of encephalitis was made. This was confirmed when he was successively an in-patient in two hospitals. He was visited nearly two years after the illness commenced. The house was not crowded, having almost as many rooms as inmates, but was not clean and somewhat untidy. The patient, who has a room for himself, was in bed. The bedclothing was scanty, makeshift and unclean. He presents the typical Parkinsonian facies. He is mentally sluggish but, given time, he was able to answer difficult questions correctly. He requires much supervision and assistance in feeding and dressing. He can do many things, but all of them slowly. He can walk fairly well; indeed he is up daily and goes out in the street every fine day. His mother thinks he is improving, but when I asked him how he was, he replied, "So-so; but-getting-worse." He eats and sleeps well. There is tremor, increased when he is up and when he makes voluntary movements of arms and hands. There is tremor also of the tongue. He complains of saliva dripping from his mouth. He himself asserts that there was no unusual lethargy at the commencement of his illness, but probably his observation and memory on the point are not to be trusted. He is at present undergoing chiropractic treatment, but his readmission to hospital is desired by his relatives. Case 6.-B. A., aged 37, butcher. He has been unfit since the beginning of his illness nearly four years ago. A diagnosis of encephalitis was made early in the course of the disease. There are no He and his wife live in a house of two rooms. children. The household income is 30s. a week, earned by the patient's wife, who goes out to work. She has to leave her husband unattended. He is scarcely fit for this, though he does |