Some Observations on the Mental Changes occurring in Encephalitis/Lethargica
- Author:
Tredgold, M.D., F.R.S.Ed.
Physician to Out-Patient Department and Lecturer, Bethlem Royal Hospital. In the spring of 1918 there appeared in England a mysterious an r ? new disease. Its main characteristics were a curious combination o n and mental changes in which lethargy, to some degree or other, occupie prominent place. For this reason it was at first called Sleeping Sickness. ,n 1 being pointed out, however, that this was the name which had for ong e . applied to an undoubtedly different disease prevalent in equatorial A rica, 1 w renamed Sleepy Sickness, and it is by this term that it is now popu ar y^ no> . Its official and scientific designation is Encephalitis Lethargica or Epi emic phalitis.
I have said an apparently new disease advisedly. For it has been remarked, with a good deal of truth, that there is nothing new under the sun, an we. this disease is really new is open to considerable doubt. At any ra e researc e into past medical records have brought to light accounts of a lsease occurring from time to time in bygone years which may well have been t e same. or instance, in Copenhagen in 1615 there was an epidemic of illness in w ic s eepi ness was a prominent symptom. There were also epidemics of a similar nature in England in 1673, in Tubingen in 1712, and in various parts of Europe in 1890. Although, after this lapse of time it is not possible to say definitely that these outbreaks were really sleepy sickness, there is reason for thinking that this probably was the case.
However this may be, the appearance of the disease in England in 1918 was followed by a rapid spread, as will be seen by the following- figures of the cases officially notified. In the year 1919, 538 cases; in 1920, 914 cases; in 1921, 1,470 cases; in 1922, 454 cases; in 1923, 1,025 cases; in 1924 (to November 15th), 4,722 cases. Personally, I have no doubt that these figures understate the real incidence, because even now, although the disease is better known and more cases are undoubtedly diagnosed, I constantly see cases which have escaped recognition.
It is clear, therefore, that if only by reason of its rate of incidence, the disease has now become one of considerable importance. This importance is increased when we learn that the death rate is high; thus of 1,273 which were investigated during the years 1919-20 no less than 48.3 per cent, proved fatal; and it is still further increased by reason of the serious mental changes which may occur in, or result from the disease. It is with these mental changes that I propose to deal.
The mental changes in sleepy sickness are best considered under two head- ings, first, those which occur during the active stages of the disease, and secondly those occurring when the patient has recovered from the acute stage and has ceased to be physically ill.
I.?Mental Changes of the Active Stage.
In a proportion of cases, beyond the characteristic sleepiness, which varies very greatly in degree, there are no mental symptoms at all. In a considerable number, however, there are mental changes of importance. The nature of these varies so greatly that it is impossible in this place to give a complete account of them; I shall, therefore, only mention the more common. Perhaps one of the most prevalent of these changes, apart from the lethargy, consists in an inability of the patient to appreciate his surroundings. If he is in a hospital ward he may think he is in some hotel, the nurse is the landlady or even his wife, the doctors are his relations or boon companions. On the other hand, he fails to recognise his wife or children and regards them as complete strangers. He not only does not know the day, or month, or even year, but he does not know whether it is morning or evening, and he may say that it is day time in the middle of the night. In other words he is in a state of imperception, dis- orientation, and mental confusion. This imperception may be so extreme that he does not recognise his own body. Thus one patient who was under my care recognised the right side of his body perfectly well, but on showing him his left hand and foot he was completely nonplussed and it was obvious that he had not the slightest idea what they were or that they belonged to him. Some patients are drowsy by day but extremely restless and excited at night. In fact during the night time they may be in a state very similar indeed to that of delirium tremens. They see animals and insects creeping up the walls, running over and under the bed, and they are kept in bed with the greatest difficulty.
They keep up an incessant chatter with people they imagine to be present. A similar condition is not uncommon in children, a number of whom, in the acute stage of the disease, suffer at night from extreme restlessness accompanied by night terrors. In a small proportion of adult cases this restlessness and excit- ability with hallucinations and incoherence of language produce a state which is practically one of acute mania, and the greatest difficulty may be experienced in restraining such persons from injuring themselves or those about them. Other cases pass through the acute stage without showing any excitement whatever, and their general condition is one of marked apathy. They are not asleep, their eyes are wide open and they appear to be noticing what is happening round them ; but to all questions they make no reply, or at most a curt monosyllable. They give the nurse no assistance whatever in her ministrations, at times they even offer a certain amount of resistance, as if objecting to being disturbed. They do not ask for food, they make no attempt to feed themselves when food is placed by their bedside, the most they will do is to swallow each spoonful as^ it is put into their mouths. Another not infrequent change is the marked impairment of memory which takes place in persons ill from this disease. On several occasions, after carrying on a conversation with a patient for a considerable time, I have gone away and returned after a short interval, but he has not had the slightest recollection of having ever seen me before.
There are many other mental changes to be seen in the acute stages of this exceedinglv interesting disease, indeed of some hundreds of cases I have never seen two precisely the same; those I have mentioned, however, are the most frequent and I think it will be obvious that they are of very great importance. Indeed, in many instances the mental alteration is so profound that the patient is certifiably insane, and some patients are actually certified and sent to asylums. I think this course is to be deprecated and it probably chiefly occurs where the real nature of the disease has not been recognised. At the same time it must be admitted that the physical signs may be so exceedingly slight that diagnosis is a most difficult, and perhaps at times, an impossible task. It is also necessary to remember that some patients are so violent that admission to an asylum is the only practicable means of ensuring their safety. Dr A. J. Hall obtained particulars from 100 asylums in England and Wales and ascertained that during the year 1918 thirty cases of Encephalitis were admitted. Some more recent enquiries made by the Board of Control, however, show that at the present time there are nearly 100 cases in Mental Hospitals. Here again I think the numbers are understated, because I have seen post-mortem evidence of Encephalitis in patients dying in asylums where the disease had not been suspected during life. II.?Later Menial Changes.
When Encephalitis first made its appearance it was commonly stated that if the patient did not die during the active stage of the disease his recovery would be complete and unattended by any ill after effects. Unfortunately further experience has completely shattered this optimistic outlook and we now know that sequelae of the utmost gravity may supervene months, or even years, after the patient has apparently recovered. Some of these after effects are on the physical side and consist of grave forms of paralysis; others are mental and these are even more serious.
Impairment of the intellectual processes of mind is seen in a proportion of cases and its disabling effects may be very severe and prolonged. One such sufferer whom I first saw two years ago had occupied a very responsible position as a confidential secretary. His intellectual impairment was so great that he could neither spell correctly many simple words, nor could he perform the most elementary mental calculations. As a result of steady persistence in progressive mental exercises he has now so far recovered as to return to clerical work. But he is quite incapable of doing what he did before his illness and occupies a subordinate position. The same thing is frequently seen in school children, who not only fail to progress but actually lose many of the scholastic accomplishments they had acquired. This intellectual impairment is usually accompanied by a marked defect of attention and memory, and a liability to fatigue on comparatively slight mental exertion. So far as my experience goes many, but by no means all, of such cases do improve in time under suitable treatment, but the excessive fatiguability makes treatment very difficult and progress very slow.
Another common after effect is seen in a lack of interest and initiative. I have known patients of either sex, who have previously been full of life and energy, scrupulously particular in their person and dress and keenly interested in home and social duties, reduced to such a state as to be utterly indifferent to anything happening round them, quite satislied to go about unwashed, unkempt and ill-clad, entirely careless as to the future of themselves or those belonging to them.
One such man told me that he realised that his wife had been compelled to sell some of her jewellery to keep the house going and that he supposed the home would have to be broken up, but he said he did not mind, he had no feel- ing at all about it. And yet, strangely enough, such people often evince an extreme degree of irritability and are apt to break out into a violent passion when pressure is put upon them, or when an attempt is made to rouse them from their inertia.
This brings me to what I am disposed to regard as perhaps the most prevalent and most serious mental change of all, namely, the profound alteration in character which is so often seen after Encephalitis. The patient has appar- ently recovered so far as bodily health is concerned. He no longer complains of headache or other pains, his temperature is normal, his appetite has returned and he is getting about. There may be some intellectual impairment, some slight weakening of memory and some inability to concentrate on anything, but the serious and important thing is that the man’s whole disposition and moral character has undergone a profound alteration. His affection for wife and children appears to be entirely gone, from being happy and good tempered he becomes sullen, sulky and extremely irritable. A chance word causes him to break out into a torrent of abuse and to use language which horrifies those about him and which he had never used before. He may threaten, or even strike those with whom he has formerly been on the most affectionate terms. He wanders off from home without vouchsafing any information as to where he is going and spends the evening at a low music hall or in a public house bar. When asked where he has been he either becomes abusive or he lies. He becomes recklessly extravagant, buying things beyond his means, and he may even steal for this purpose. In short, he seems ,to have lost all moral sense, all self-respect and wisdom, and to have become utterly depraved, irresponsible, and indifferent to the feelings of his family. Fortunately this state of affairs is not very common in adults, but it does occur, and it can readily be seen how dire the consequences may be, more especially so if the nature of the disease has not been recognised. Such a person may easily suffer imprisonment for acts which would formerly have horrified him and for which he is certainly not responsible.
But while this serious state of affairs is relatively rare in adults, it is unde- niably far from being so in children, and the number of these latter in whom a marked intellectual or moral degradation has taken place has become so great as to constitute a very real and pressing- social problem. Regarding this, I may mention that Dr F. C. Shrubsall, Principal Assistant Medical Officer of the London County Council, has been good enough to inform me that at the present time in the London area there are between 200 and 300 school children who show serious intellectual or conduct disturbance as a result of this disease. There is not the slightest doubt that similar results have followed elsewhere, so that the total number of such children throughout the country must be very con- siderable. In some of these cases it is the intellectual functions of mind which have chiefly suffered. The child who had previously been bright becomes dull. He can no longer do the work of the standard he was in before his illness ; he may even lose some of his acquirements and the school knowledge he had formerly possessed. His power of attention and concentration is impaired, he is no longer capable of making- mental effort and he becomes fatigued and confused in the attempt to do so. In a considerable number of cases the intellectual impair- ment is so pronounced that the child conforms to the definition of a mental defec- tive given in the Education Act, in that he is ” incapable of receiving proper benefit ” from the instruction in a public elementary school.
In other children, with or without this impairment of educability, there is a marked alteration in the whole disposition and behaviour. The child who had previously been a well-behaved and affectionate member of the family, ceases to show, and apparently to feel, any affection for his parents and relations. He becomes obstinate, sullen, irritable and aggressive, addicted to outbreaks of passion and sudden impulses, often cruel to animals and young children. He is utterly unresponsive to, and intolerant of, any attempts to reason with him or check him in his misbehaviour. He pilfers and thieves without the slightest com- punction. He will take all the ready money he can lay his hands on and disappear for the day, perhaps being found in difficulties of some kind or other miles away from home and being brought back by the police. He lies without scruple, and although some of his lies are directed towards getting him out of some of the troubles he has brought upon himself, and avoiding punishment, in many in- stances they are quite gratuitous and serve no purpose at all. He seems to take a malicious and fiendish delight in doing damage. One such child who was brought to see me, a girl of ten years, took a box of matches and deliberately set fire to the next door neighbour’s perambulator. It is difficult, indeed almost impossible, for those who have not had actual experience of cases of this kind to realise how great may be the change in disposition and behaviour, and what serious and seemingly wicked and senseless acts such children may commit. Again and again I have been told by a parent that a child whose behaviour had pre- viously been irreproachable has now become a veritable little fiend.
There can be no doubt that in the cases I have just described there is a very serious impairment of both moral feeling and common sense. The altera- tion of moral feeling is shown by the lack of affection and self-respect, the want of all sense of obligation and responsibility, and the absence of all shame and remorse for misdeeds. Perhaps some contrition may be expressed, but it is evident that there is no real feeling of shame; on the contrary some of these children seem to glory in their misconduct. The want of wisdom or common sense is shown in such children by the utter senselessness of their acts, by the fact that even in the cases where these bring them a temporary gratification this is but short lived, so that in the long run the disadvantage by far outweighs the advantage, also by the fact that they are undeterred by punishment and are in- capable of profiting by experience. Indeed, with regard to the nature of the misconduct of these children, also, I think, with regard to the psychology under- lying this, many of them are indistinguishable from that class of defectives known as moral imbeciles.
I have seen a few cases in which, whilst the general misbehaviour is similar, the mental disorder underlying it appears to me to be slightly different. In these the child does show evidence of shame and regret for the acts he has committed. In other words, he not only knows, but he feels that he has done wrong. But he still persists in his misbehaviour, he is still undeterred by punishment, and he says that he misbehaves because something seems to come over him and he cannot help himself. I think it is likely that in cases of this kind the region of the brain chiefly affected by the disease has been that concerned with the function of control.
Such then are some of the chief mental changes which may follow this extraordinarily interesting-, but truly terrible disease. It is of extreme interest for several reasons. In the first place it affords additional confirmation of the rela- tionship between mind and brain tissue. It demonstrates how changes in this latter, which are often for the most part microscopical, may be attended with very marked alteration of intellectual capacity, of feeling, judgment, control, and of the whole disposition and personality of the individual affected. The relation- ship of mind to brain has, of course, long been recognised, but it is of great importance to realise that the mental changes I have mentioned may follow an attack of Encephalitis of such a mild character that its real nature has not been recognised at the time of its occurrence, and has only come to light when careful enquiries have been instituted at a later date. Moreover, there is no doubt that what is known as an ” ambulatory ” type of the diseasp may occur, that is to say that persons may suffer from Encephalitis and yet at the time not feel ill enough to seek medical advice. It is more than probable, there- fore, that mental changes which are really a consequence of this disease may occur in a person who has had no obvious illness. Another point of great in- terest is the possible light which the disease may throw upon the localisation of the various processes of the mind. As I have already stated, the after effects may be of the most varied kind. In some cases there are none at all, in others there are various forms of paralysis, or of tremor and rigidity, but the mind remains unaffected. In yet others the change is entirely mental, and it may then consist of intellectual impairment, of a deterioration of moral feeling, of a weak- ening of judgment, an incapacity to profit from experience, or of a loss of control.
This surely suggests that these different functions have localisations in the brain cortex which further research may reveal. Assuming, as I think we must assume, that these changes are the consequence of alterations in the cells of the brain, the question naturally arises as to the relationship of these cases in children to Mental Deficiency. Are children affected in this way certifiable under the Mental Deficiency Act? The definitions given in the Act say that the mental defect must have been present ” from birth or from an early age ” and it is sometimes stated that an early age means the early years of infancy, and that a child whose mental development has been normal up to, and has been arrested from, say 12 or 14 years, cannot be regarded as a defective within the meaning of the Act. In my opinion this is a complete mistake. I consider that the words ” from an early age ” were primarily used for the purpose of distinguishing arrested, or incom- plete mental development, from the decay of mind which occurs after development has been completed, and that the correct interpretation of the term is any age anterior to this period. Generally speaking this may be said to be about the age of 16 years, although in some cases it may be later. If, therefore, as a result of Encephalitis, the functions of mind are arrested in their development to such a degree as to prevent the individual from ” managing himself or his affairs,” or are such as to necessitate ” care, supervision and control for his own protection or for the protection of others,” I should certainly consider that the person was certifiable under the Mental Deficiency Act. It is necessary to remark, however, that although the Act does not say that the defect must be permanent, it is unde- sirable to certify such cases so long as there is a reasonable prospect of their recovery. Some of these cases do slowly improve, the functions of mind have been embarrassed in their development, but have not been entirely arrested. It is, therefore, wise to allow of a reasonable time for improvement to take place before resorting to certification under the Act.
This raises a very important administrative problem with regard to the class unable to pay for private care. If it is inadvisable without some delay to certify such children and young persons under the Mental Deficiency Act, and the same applies to certification under the Lunacy Act, what is to be done with them ? Some of those whose educational capacity has been seriously impaired, and whose conduct is not too outrageous, may possibly be dealt with by being” sent to a resi- dential special school under the Educational Act. But the proportion of these is relatively small, and there are many children who are quite unfit for a residential school, but who are in urgent need of institutional caic. At the piesent time no suitable provision exists for these children, in spite of the fact that they arc a numerous class and that they constitute a very serious social menace. Prison, of course, is worse than either the asylum or the institution foi defectives. I am inclined to think that the best solution of the problem would be the founda- tion of a special establishment with adequate medical supervision, undei th^. administration of the Ministry of Health or the Home Ofiice.
It is clear, therefore, that while the disease presents many points of extreme interest, it is nevertheless a very terrible one. At the present time 0111^ expci ience is not sufficiently lengthy to enable us to say in what proportion the changes I have described will prove to be permanent. I have seen cases which under judicious management, have slowly, but very slowly, improved. On the other hand, 1 have seen cases which have shown no real improvement after several years. There cannot be the slightest doubt that a proportion, and probably a considerable one, will remain permanently cripplcd in either body or mind. And the mental crippling is either a serious intellectual impairment with consequent social inefficiency, or, what is even worse, a deterioration of those highest func- tions of mind which are concerned with the regulation of conduct and this must inevitably lead to crime and social disorder.
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