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and the prevention of crime. The league has beenactive and watchful, and to-day most of the horrorsseen, and sometimes practically experienced, byHoward have disappeared from this country, althoughthey remain rooted in certain European countries.Howard did noble and progressive work, and hisstatue in St. Paul’s Cathedral bears testimony to hisservices to mankind.

SERUM TREATMENT OF TUBERCULOSIS

OF all the immunological remedies for tuberculosis,antisera have been the most disappointing. FromSweden comes an account of clinical experimentswith a new one, produced by Reenstierna, which isprepared by the inoculation of sheep with antigenscomposed of acid-fast and non-acid-fast (coccoidand diphtheroid) forms of the tubercle bacillus. The

sheep is immunised by subcutaneous injections givenevery ninth or tenth day over a period of four months,starting with 5 c.cm. of the acid-fast and 10 c.cm.of the non-acid-fast forms and finishing with 100 c.cm.and 400 c.cm. So far Reenstierna has not been ableto devise a satisfactory method of standardisationof the serum and therefore the dosage has had to begoverned chiefly by trial and error. Hanson hastested the serum on patients at Apelviken, the largestsanatorium in Sweden, and his material includes21 cases of lupus, 52 of glands of neck, 7 of cutaneoustuberculosis, 11 of tuberculosis of the eye, and 41 oftuberculosis of bones and joints, making a total of132 cases. The lupus cases did very well, as shownby illustrations included in Hanson’s paper. For therest, the results appear to be variable. A focalreaction analogous to that which follows tuberculinsometimes followed the injection, but no otherabnormalities were noted and there were no cases

of anaphylactic shock. Although the work is merelyin a preliminary stage it seems worth continuing.

EPIDEMIC ENCEPHALITIS

SEVERAL outbreaks of encephalitis have been

reported from the United States during the pastfew years. Most of them have affected comparativelysmall areas, and though they have differed in certainminor features, they have all had this in common-that they were something different from therecurrent epidemics of encephalitis that began in

Europe during the late war. Up to now the largestof these outbreaks is the St. Louis epidemic of 1933in which there were more than 1000 cases. In theone which affected Windber in Pennsylvania lastyear there were only 160 patients, but Dr. Slesinger’saccount 2 of it contains many facts of interest. Theseason was July and August ; the maximum incidencewas from July 25th to August 7th, and the peak onJuly 30th. The proportion of males to females affectedwas about 3 to 2, and there were only 17 patientsover thirty and only 6 under two years of age. Thedisease was highly contagious, and the clinicalfeatures were always much the same. Suddenheadache of great severity was followed by nauseaand perhaps vomiting. The headache was usuallyoccipital, but pains also occurred in other parts ofthe head and in the trunk, including backache andabdominal cramps. Generalised muscular pains andvertigo were often persistent and troublesome, andsleeplessness was not uncommon.

Physical signs were few. In a few of the more severecases there was slight stiffness of the neck and a moderately

1 Hanson, R. : Acta Med. Scand., 1936, Suppl., lxxiii.2 Slesinger, H. A. : Acute Epidemic Encephalitis—a Clinical

Study of 160 Cases, Amer. Jour. Med. Sci., August, 1936, p. 225.

positive Kernig’s sign. In a few cases, too, the pupilswere irregular. The soft palate always showed charac-teristic changes : it was injected and presented a finevesicular eruption giving a strawberry-like appearance.The temperature was only slightly raised and usuallyfell to normal in two or three days. The pulse-rate wasrather slow. The blood count with rare exceptions wasnormal. In 32 cases lumbar puncture was performed,and in all but 2 of these the fluid was clear : in one ofthese it was opalescent, in the other it was bloody. Asa rule pressure was slightly increased. ’Globulin waspresent in all cases. Cell counts were usually increasedto between 50 and 100 ; the highest was 670, and thecells were lymphocytes. The amount of sugar in thecerebro-spinal fluid was normal or slightly decreased.

The attacks could be divided into three types :(1) the mild or abortive, in which acute symptomslasted only about 24 hours; (2) the moderatelysevere, which lasted for a week or so, sometimeswith headache persisting for several weeks; and

(3) the severe, or fulminating. The last groupcontains only one case, that of a boy aged 13 whowas taken suddenly ill, went rapidly into coma, anddied after two days. At autopsy numerous petechialhaemorrhages were found throughout the brain, anda large area of h2emorrhage in the posterior end ofthe thalamus which had burst into the lateralventricle. " The findings are those of an acute

haemorrhagic meningo-encephalitis." Among the159 who recovered there were seldom any com-plications or sequelae : only 7 complained of after-effects, and three months after the outbreak allwere well except 1 who still had some headache andvertigo. After the first ten days convalescent serum,obtained from earlier cases, was used in the moresevere attacks, and it was thought to reduce theduration and severity of symptoms. It was alsogiven prophylactically to the 7 members of thehospital staff most exposed to infection, none ofwhom developed the disease.

It will be noticed that in most ways this outbreakis very different from the form of encephalitis withwhich Europe has been familiar in the past, to whichthe name encephalitis lethargica was originally givenby Economo in 1917. The seasonal incidence, modeof onset,’ contagiousness, course, and sequels are

none of them the same ; indeed, almost the onlysimilar features are the sex- and age-incidence.Quoting the terminology proposed in the St. Louisreport,3 Slesinger assigns the Windber outbreak toGroup II. of the following classification :

Group I.-Type A encephalitis or encephalitis lethargica(encephalitis of Economo).Group II.-Type B encephalitis or epidemic encephalitis

(Japanese form and St. Louis form). (Italics are ours.)Group III.-Post- or para-infectious encephalitis.Group IV.-Other forms of encephalitis, such as post-

vaccinial.

According to this scheme, the adjective " epidemicis reserved for encephalitis of Type B, such as isseen in Japan and the United States, and we cannothelp thinking this a source of confusion to thosewho consult the vast literature of encephalitisaccumulated during the past two decades. Althoughin England the Registrar-General still retains theterm " encephalitis lethargica " for purposes ofofficial notification, the medical profession generallyhas largely abandoned it both in speaking and inwriting, using in preference the term " epidemicencephalitis " (sometimes, it is true, adding

3 Report on the St. Louis Outbreak of Encephalitis. U.S.Pub. Health Bull., No. 214, 1935.