attempted this form of treatment in thirty cases. This represents 8.3 per cent. of the patients dealt with in this sanatorium. In five of these the operation was impossible owing to pleural adhesions.

The Superintendent considers the following to be indications for treatment disease of one lung only; sanatorium treatment tried for at least three months without improvement; marked toxæmia; recurrent hæmoptysis if it is possible to diagnose the lung from which the blood is coming; chronic pleurisy with effusion or recurrent dry pleurisy.

Of seventeen cases in which the collapse of the lung was complete, all improved for a time after the operation, ten have recovered and are back to full work in a city, and seven have died from the disease at a longer or shorter interval.

Of eight cases where the collapse of the lung was only partial, all shewed improvement for a time, but six ultimately died, one is quite well, and one is still under treatment.

(j) Dr. Johnstone, Tor-na-Dee Sanatorium, states that no patient, whatever the stage of the disease, should be subjected to the possible dangers and complications of artificial pneumothorax without strong reasons and without fair trial of less drastic methods. Like every other good remedy, artificial pneumothorax is often applied to unsuitable cases by misguided enthusiasts, with the result that its reputation suffers both amongst doctors and patients. Acute pneumonic phthisis may sometimes be treated by this method, but a high proportion of fatalities must be expected in these. He adds that it is sometimes good practice to treat pleurisy with effusion, serous or purulent, by this method, and also cases with hemorrhage where this cannot be controlled by the more usual methods. cases in which artificial pneumothorax may sometimes be advisable are those enjoying good general health but having copious sputum containing tubercle bacilli; cases with post-tuberculous bronchiectasis, mainly unilateral; and cases keeping fairly well so long as they lead very restricted lives but taking febrile attacks on slight provocation.

Other

During the past seven years Dr. Johnstone has treated sixtythree patients by this method. Of these the pneumothorax was complete or almost complete in twenty-one cases. Sixteen of the twenty-one improved, these being all alive and well. Of the five which did not improve three are dead, one is well following subsequent thoracoplasty and one is ill. In nineteen cases the collapse was partial, thirteen of these being well, five dead and one ill. In twenty-three cases pneumothorax was impossible; of these nine are dead, two are well, six are ill, while in the six remaining cases thoracoplasty was carried out later. Of these thoracoplasty cases all except one are alive and well.

(k) Bridge of Weir Sanatorium. During the past five years Dr. Crocket has attempted this form of treatment in 243 cases

(i.e. nearly one-half of the cases dealt with in this summary). In fifty-two cases it was unsuccessful, usually because of pleural adhesions. In 111 it was not satisfactory or the patients did not respond to the treatment in any way. In fifty-four cases it was really beneficial, and in most of those instances the improvement was striking and has been permanent. In twenty-six cases the results were only fair or partially satisfactory.

CHAPTER IV.

ENCEPHALITIS LETHARGICA.

1. A New Disease.-A little less than ten years ago, towards the end of the war, there appeared in Austria and France what seemed to be a new disease. A year later, in the spring of 1918, it was discovered in two parts of England. Almost immediately afterwards it was recognised and described in the west of Scotland; and within a year thereafter it had made its appearance and been identified in America. This malady, called Encephalitis Lethargica by Von Economo in Vienna, who first described it, manifests itself in extremely varied forms. It may be initially so mild that its essential nature is not at the time suspected; or so virulent that death may occur within a few days of the first sign of illness. Moreover, although the several forms of the malady tend to fall into a few main types, the actual manifestations or symptoms are extremely varied. No single symptom is pathognomic; but the "classical" indications of the disease in its early and more acute stage are fever, lethargy, myoclonus, and disturbance of the action of the eye muscles. Even these symptoms, although the most characteristic of the disease towards its commencement, are not invariable; for some patients have the element of fever, if they have it at all, so slight and ephemeral that they are able to continue at work throughout their illness. In others, again, there is little or no somnolence or lethargy. or lethargy. Thus the name of encephalitis lethargica or its vernacular equivalent of sleepy sickness is inappropriate in a considerable proportion of cases.

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Instead of Encephalitis Lethargica," it has been proposed to call the malady" Epidemic Encephalitis." The latter term is doubtless more appropriate, but the other has already received official sanction, is generally familiar, and is not likely to be misleading. It is, therefore, probably expedient to retain it.

2. General Incidence and Distribution.-After its first appearance in Europe in 1917 and in England in 1918, this disease spread rapidly, so that it was soon reported from almost all parts of the world, including Japan, Canada, South America and South Africa (where the native population was considerably affected). In England and Wales it was made notifiable from 1st January, 1919. In the years 1919 to 1925 inclusive, 12,054 cases were so notified in these countries. In the light of what is known of the slight and transient nature of a proportion of the cases, it may be regarded as certain that a far greater number of cases occurred than were recognised and notified. Of the 12,054 cases notified in England in the seven-year period ending 1925,

* See paragraph 12.

5,039, or nearly one-half, were notified in the year 1924. In the following year (1925), the number reported was only a little more than half as many (2,635). Of the cases notified in England in the seven-year period, 1,490, or about one-eighth of the whole, were in London.

3. Incidence in Scotland.-As has been said, the disease was recognised in Scotland early in 1918. During the summer and autumn of that year a number of cases were described; but until 1923 it remained an uncommon or at least unfamiliar disease in most parts of the country. From time to time certain local authorities added it to the list of notifiable diseases, until by March, 1925, ten areas had done so. Under these local arrangements, 110 cases were notified in 1923 and 707 in 1924. If, as is likely, a proportion of these were diagnosed incorrectly, it is highly probable that the error is more than counterbalanced by the number of actual cases that passed unrecognised. The deaths registered in Scotland and ascribed to this cause were 125, 181 and 154 in 1923, 1924 and 1925 respectively; and 503 in the five-year period 1920 to 1924 inclusive. The disease was not made generally notifiable (by Regulation of the Board of Health framed in terms of Section 78 of the Public Health (Scotland) Act, 1897) until 1st January, 1926, so that precise figures for the whole country are not available before that date. Apparently, however, the disease, in Scotland as in England, became gradually more prevalent until 1924 was reached. Since then, it is believed, there has been a definite diminution of incidence. In the year 1926, 278 cases were notified, and the deaths ascribed to the disease were 169. During that year there came to the knowledge of the authorities a great number of cases whose actual commencement dated from 1924 or even earlier; cases whose real nature had not been evident at the time of onset, but which were diagnosed indubitably upon the supervention of the later and more distinctive phase-the so-called "sequelæ which form a feature of a proportion of cases of the illness. Encephalitis lethargica was made notifiable in Glasgow in 1918. During the six years 1920-25 inclusive, 683 cases were recorded and 161 of these died. More than one-half of these cases and about onethird of the deaths occurred in 1924. Of the 522 survivors, it is probable that at least one-half have permanently suffered in body or in mind as a result of the attack. In Glasgow at the present time (December, 1926) there are believed to be a large number-variously estimated at from 400 to 600, but possibly considerably in excess of the latter figure-who are suffering from the gravely incapacitating symptoms of the late and chronic phase of the disease. There is some reason to think that the malady reached a higher incidence in the south and west of Scotland than in the north and east. Its incidence seems to be relatively higher in the industrial areas where the population is most closely aggregated, than in the rural districts. There is no ground for believing that it specially affects the poorer section of the community; and there is nothing to indicate that either

the structure of a house as regards its repair and general hygienic state, or its condition as regards cleanliness, has any effect in determining incidence. Among those who have studied the malady there is general agreement that it is not a disease of poverty or the slums. Indeed it has been suggested that households of the comfortable artisan class seem to have been more prone to be affected than the average; and it is certain that even the well-to-do are not much less liable to acquire the infection than the average of the population.

4. Seasonal Incidence.-Experience has shewn that this disease is usually more prevalent in winter and spring than in summer and autumn, the first quarter of the year being as a rule the time when it is most common. It may be, however, that this is due to the fact that during the less clement months people spend a larger proportion of their time indoors, and that, owing to a desire to maintain a comfortable house temperature, they are apt to live under less airy and less wholesome conditions than in the time of warmer weather.

5. Influence of Sex, Age and Occupation.-It appears that the sexes are about equally liable to be attacked by this disease. No age is immune, but children and adolescents are much more prone to be affected than those at other ages. About one-fourth of all the cases occur in persons in the second decade of life, and of these cases the majority are in the latter half of that period. Occupation, in itself, does not seem to have any relation to the disease, except that in this as in other maladies in which infection is doubtless an essential feature, those whose duties entail indoor lives are liable to be attacked in larger proportion than others. It is noteworthy that medical practitioners and nurses have not been especially liable to this disease. This is what might be expected from what is otherwise known of its epidemiology.

6. Essential Nature.-Encephalitis lethargica is an inflammatory affection of the central nervous system. Its most frequent and characteristic symptoms are fever, progressive lethargy or stupor, and disturbance of function arising in or about the third pair of cervical nerves, causing abnormalities of the movements of the eyes and face. Though the organism causing it has not been found, analogy leaves no reason to doubt that it is due to a micro-organism and is therefore of essentially infectious nature, low though the infectivity unquestionably is. It is now generally held that, beginning as an acute, if sometimes very mild, disease, it runs or is capable of running a very protracted course; that what were formerly described as sequelæ of the disease are rather to be regarded as signs of a continuing, though at that stage very chronic, malady; and that the manifestations of this late stage are often much more distinctive or diagnostic than those of the early phase.

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7. General Description.-Encephalitis lethargica, then, has been described as "an acute general disease associated with