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A CASE OF PARKINSONISM WITHOUT INITIAL SYMPTOMS OF ENCEPHALITIS.
872 for about three months, but the periods had recently come on again ; she did not think there had been any question of pregnancy. Apart from the question of age and the absence of the characteristic pill-rolling movements, the early and comparatively sudden appearance of the mask-like face in this patient was the principal feature which made me think at once of encephalitis lethargica. The interesting features of the case were the insidious onset and the complete absence of evidence of the previous occurrence of any of the sudden symptoms or febrile manifestations which usually characterise the onset of this disease. For this reason this case appears to me to belong to a type which, so far as I am aware, has not hitherto been recorded, namely, that of encephalitis lethargica,—" forme fruste "in which no characteristic symptoms occur in sufficient quantity to attract the attention of the patient or his friends. While in the ordinary types the acute period of the disease may be so short as to be forgotten by patients, a careful review will usually reveal some feature or features which enable one to trace the date of onset with fair accuracy. It is interesting to note that the only previous symptoms mentioned by this particular patient were those of dyspepsia, and it is recognised that gastro-intestinal disturbances may sometimes occur as early symptoms of lethargic
submit, ’’ Economo’s disease " is a than encephalitis lethargica," where neither lethargy nor evidence of encephalitis is essential to the diagnosis ; it entails no misapprehension ; in fact, it avoids any. As Prof. A. J. Hall has well said, in his Lumleian lectures, the name encephalitis lethargica survives; chiefly from reasons of sentiment, since it is the one selected by von Economo. By retaining it we pay tribute to his remarkable work ; a work renderedL
Similarly, better
I would
designation
"
"
’
’
remarkable by the fact that it was carriedL at the height of a great war, under all the. difficulties which that involved." I share this sent,iment, but think it would be better expressed by giving to the disease the name of its discoverer. When Freiherr von Economo chose the present name, it covered the known facts ; now he would probably be the first to admit it no longer does so. His name is so) familiar in connexion with the disease that the one immediately recalls the other. I believe the adoptioni of the term " Economo’s disease " would tend to clearr the path of further observation. I am, Sir, yours faithfully, W. GORDON. 1923. Exeter, April 17th,
even more
out
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A CASE OF PARKINSONISM WITHOUT INITIAL SYMPTOMS OF ENCEPHALITIS.
encephalitis.-I
am,
Sir. yours faithfully,
MAURICE DAVIDSON.
To the Editor of THE LANCET.
Wimpole-street, W., April 20th, 1923.
SIR.—Prof. A. J. Hall has referred in his recent Lmnleian lectures to the clinical differences between Parkinsonism and the pre-senile form of paralysis agitans. The following case illustrates some of the points in this connexion. The patient, a married ’ of about 35. first came to me as an woman out-patient at the Miller Ilospital in March of this year. She had been treated for some months for indigestion, she always felt tired, took little, or no interest in things, and merely wanted to sit about. Her general appearance was characteristic of the Parkinsonian type of disease; she had a mask-like expression. and the typical slow progression and stiff attitude of body with the arms held a little forward, the elbows being slightly flexed. There were none of the movements commonly seen in the ordinary pre-senile type of paralysis agitans, and the clinical picture suggested the Parkinsonian sequelæ of lethargic encephalitis. I went carefully into the previous history expecting to get a story of an attack of so-called influenza, but was unable to elicit ani account of any definite febrile period. I saw the, patient again at my house together with Prof. Hall. She had not been conscious of any visual disturbances such as might have suggested ophthalmoplegia. The indigestion of which she had complained begani apparently about a year ago, a point of some importance, in connexion with the seasonal incidence of the disease. She slept well and could go to sleep easily at any time that she liked, but there was no evidencE of her having had any involuntary lethargic periods. On examination the first and most obvious signs werE the rigidity of the upper limbs, the general posture and the mask-like features and extremely fixec expression. The pupils reacted to light and accommo dation, but the latter reaction was sluggish and th( accompanying convergent movements of the eye; ill-sustained. There was no trUt were weak and nystagmus, but slight nystagmoid movements and a certain weakness were apparent on extreme latera movement. There was evident difficulty in fixing objects. The fundus oculi appeared normal on botl sides. When the patient was asked to open the han( quickly after making a fist, there was some hesitation and slowness in extension of the fingers. A sligh fine tremor was observed when the arms wer’ extended. There was a definite fine tremor of th, tongue and slight hemi-atrophy affecting the left side Some tremor of the lips was also noticed. The knee jerks were easily obtained and were brisk on both sides Her general health was good, the indigestion havin; by this time disappeared. She had had amenorrhoE. ’
,
,
.
-
.
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THE LIFE-HISTORY OF THE TAPEWORM, HYMENOLEPIS NANA. To the Editor
of THE LANCET. issue of SiR,—In your April 21st my friend, Dr. Wm. Nicoll, corrects a slightly misleading state" ment occurring in a recent issue of the Tropical Diseases Bulletirz to the effect that Nicoll and Minchin claim to have obtained cysticercoids of Hymenolepis rzarza in fleas. Dr. Nicoll states that no claim was intended, and that there is nothing in the published report (Proc. Zool. Soc., 1911) to suggest such. As the statement referred to occurred in a review of recent contributions to medical helminthology written by me for the Bulletin, I may be allowed to say that the claim attributed to Dr. Nicoll and Prof. Minchin rests upon the authors’ abstract published by the Zoological Society, November, 1910, which states that one of the cysticercoids found in the fleas " was probably the larva of Hymenolepis nzurina, a species occurring in rats and mice and very similar to, possibly identical with, H. nana, a dangerous tape" The chief interest of the discovery worm of man." lay in the fact that no intermediate host was previously known for this tapeworm." The last sentence (italicised by me) forms the basis of the statement of which Dr. Nicoll complains.—I am, Sir, yours faithfully, R. T. LEIPER. London School of Tropical Medicine, Endsleighgardens, London, N.W., April 24th, 1923. "
HOFMANN’S BACILLUS AND TONSILLITIS. To the Editor of THE LANCET. SIR,—In THE LANCET of April 21st Dr. David Smith takes me to task for assuming that Hofmann’s bacillus is non-pathogenic. In the work in question the majority of the organisms came from boys without symptoms, and these strains were presumed to be non-pathogenic. However, I should not like to maintain that bacilli with a morphology of the Hofmann type can never cause symptoms. Pathogenicity is an attribute that seems very variable, and under the influence of a suitable environment it is quite conceivable that certain strains of Hofmannlike bacilli are sometimes pathogenic. Many times in sore throats, not resembling diphtheria, I have found Hofmann bacilli as predominant organism, yet in the light of my own experience I have hesitated to ascribe an ætiological significance to this fact.
submit, ’’ Economo’s disease " is a than encephalitis lethargica," where neither lethargy nor evidence of encephalitis is essential to the diagnosis ; it entails no misapprehension ; in fact, it avoids any. As Prof. A. J. Hall has well said, in his Lumleian lectures, the name encephalitis lethargica survives; chiefly from reasons of sentiment, since it is the one selected by von Economo. By retaining it we pay tribute to his remarkable work ; a work renderedL
Similarly, better
I would
designation
"
"
’
’
remarkable by the fact that it was carriedL at the height of a great war, under all the. difficulties which that involved." I share this sent,iment, but think it would be better expressed by giving to the disease the name of its discoverer. When Freiherr von Economo chose the present name, it covered the known facts ; now he would probably be the first to admit it no longer does so. His name is so) familiar in connexion with the disease that the one immediately recalls the other. I believe the adoptioni of the term " Economo’s disease " would tend to clearr the path of further observation. I am, Sir, yours faithfully, W. GORDON. 1923. Exeter, April 17th,
even more
out
-
A CASE OF PARKINSONISM WITHOUT INITIAL SYMPTOMS OF ENCEPHALITIS.
encephalitis.-I
am,
Sir. yours faithfully,
MAURICE DAVIDSON.
To the Editor of THE LANCET.
Wimpole-street, W., April 20th, 1923.
SIR.—Prof. A. J. Hall has referred in his recent Lmnleian lectures to the clinical differences between Parkinsonism and the pre-senile form of paralysis agitans. The following case illustrates some of the points in this connexion. The patient, a married ’ of about 35. first came to me as an woman out-patient at the Miller Ilospital in March of this year. She had been treated for some months for indigestion, she always felt tired, took little, or no interest in things, and merely wanted to sit about. Her general appearance was characteristic of the Parkinsonian type of disease; she had a mask-like expression. and the typical slow progression and stiff attitude of body with the arms held a little forward, the elbows being slightly flexed. There were none of the movements commonly seen in the ordinary pre-senile type of paralysis agitans, and the clinical picture suggested the Parkinsonian sequelæ of lethargic encephalitis. I went carefully into the previous history expecting to get a story of an attack of so-called influenza, but was unable to elicit ani account of any definite febrile period. I saw the, patient again at my house together with Prof. Hall. She had not been conscious of any visual disturbances such as might have suggested ophthalmoplegia. The indigestion of which she had complained begani apparently about a year ago, a point of some importance, in connexion with the seasonal incidence of the disease. She slept well and could go to sleep easily at any time that she liked, but there was no evidencE of her having had any involuntary lethargic periods. On examination the first and most obvious signs werE the rigidity of the upper limbs, the general posture and the mask-like features and extremely fixec expression. The pupils reacted to light and accommo dation, but the latter reaction was sluggish and th( accompanying convergent movements of the eye; ill-sustained. There was no trUt were weak and nystagmus, but slight nystagmoid movements and a certain weakness were apparent on extreme latera movement. There was evident difficulty in fixing objects. The fundus oculi appeared normal on botl sides. When the patient was asked to open the han( quickly after making a fist, there was some hesitation and slowness in extension of the fingers. A sligh fine tremor was observed when the arms wer’ extended. There was a definite fine tremor of th, tongue and slight hemi-atrophy affecting the left side Some tremor of the lips was also noticed. The knee jerks were easily obtained and were brisk on both sides Her general health was good, the indigestion havin; by this time disappeared. She had had amenorrhoE. ’
,
,
.
-
.
-
THE LIFE-HISTORY OF THE TAPEWORM, HYMENOLEPIS NANA. To the Editor
of THE LANCET. issue of SiR,—In your April 21st my friend, Dr. Wm. Nicoll, corrects a slightly misleading state" ment occurring in a recent issue of the Tropical Diseases Bulletirz to the effect that Nicoll and Minchin claim to have obtained cysticercoids of Hymenolepis rzarza in fleas. Dr. Nicoll states that no claim was intended, and that there is nothing in the published report (Proc. Zool. Soc., 1911) to suggest such. As the statement referred to occurred in a review of recent contributions to medical helminthology written by me for the Bulletin, I may be allowed to say that the claim attributed to Dr. Nicoll and Prof. Minchin rests upon the authors’ abstract published by the Zoological Society, November, 1910, which states that one of the cysticercoids found in the fleas " was probably the larva of Hymenolepis nzurina, a species occurring in rats and mice and very similar to, possibly identical with, H. nana, a dangerous tape" The chief interest of the discovery worm of man." lay in the fact that no intermediate host was previously known for this tapeworm." The last sentence (italicised by me) forms the basis of the statement of which Dr. Nicoll complains.—I am, Sir, yours faithfully, R. T. LEIPER. London School of Tropical Medicine, Endsleighgardens, London, N.W., April 24th, 1923. "
HOFMANN’S BACILLUS AND TONSILLITIS. To the Editor of THE LANCET. SIR,—In THE LANCET of April 21st Dr. David Smith takes me to task for assuming that Hofmann’s bacillus is non-pathogenic. In the work in question the majority of the organisms came from boys without symptoms, and these strains were presumed to be non-pathogenic. However, I should not like to maintain that bacilli with a morphology of the Hofmann type can never cause symptoms. Pathogenicity is an attribute that seems very variable, and under the influence of a suitable environment it is quite conceivable that certain strains of Hofmannlike bacilli are sometimes pathogenic. Many times in sore throats, not resembling diphtheria, I have found Hofmann bacilli as predominant organism, yet in the light of my own experience I have hesitated to ascribe an ætiological significance to this fact.