1015

never established and it seemed incredible that so

disastrous a pandemic should appear suddenly and dis-appear altogether within the space of a dozen years.While textbooks generally say that no new cases havesince been seen, sporadic cases thought to be encephalitislethargica are reported from time to time. And patientstoo young to have lived through the epidemic are seenwith postencephalitic syndromes. If the infection hasnot vanished, does it perhaps lurk under other guises ? ?And is recrudescence still a possibility ? Other types ofprimary epidemic virus encephalitis have appeared indifferent parts of the world; and many neurotropicviruses responsible for epidemic and sporadic cases havebeen identified. But only the lethargic type seems to befollowed by the characteristic extrapyramidal syndromewith residual oculomotor disturbances and oculogyriccris es. 10

The letter from Dr. HUNTER and Dr. JONES on p. 1023reports 6 recent cases of encephalitis with features of thelethargica type which presented with a variety of

psychiatric syndromes against the background of mildor moderate cerebral impairment. There is no sug-gestion of an epidemic and no proof that this illness isidentical with encephalitis lethargica. The patientsbecame ill at scattered intervals over a period of at leastfifteen months and presumably they also came fromdifferent localities. Nor does diagnosis made on clinicalgrounds alone necessarily implicate a single in-fective agent, since infection with different types of virus

may produce a common clinical picture." The results ofvirological investigations which are proceeding may helpin identification, though they give positive results in onlyabout half of all patients with encephalitis.12 Examina-tion of the brain of the one patient who died of thedisease may also indicate the type of infection, althoughGREENFIELD 13 found that sporadic cases of encephalitislethargica may not show the selective damage in thesubstantia nigra that is found in epidemic cases. Sporadiccases may have more severe lesions in the cortex.

Ultimately the development of the postencephaliticstate may be decisive. The unexpected appearance of apostencephalitic syndrome in another patient undertheir care first led HUNTER and JONES to think of

lethargica-type encephalitis.Did these patients have a psychiatric illness inde-

pendent of their neurological illness ? None had a historyof previous breakdowns, except one who had had anattack of the same kind. Mental symptoms and physicalsigns seemed to run a parallel course, and eye signs andstupor or confusion improved simultaneously afterlumbar puncture-also a common but unexplainedobservation made during the epidemic in the 1920s.14 159. Fields, W. S., Blattner, R. J. Viral Encephalitis. Springfield, Ill., 1958.10 Duvoisin, R. C., Yahr, M. D. Archs Neurol. 1965, 12, 227.11. Meyer, H. M., Jr., Johnson, R. T., Crawford, J. P., Dascomb, H. E.,

Rogers, N. G. Am. J. Med. 1960, 29, 334.12 Klemola, E., Kääriäinen, L., Ollila, O., Petterson, T., Jansson, E.,

Haapanen, L., Lapinleimu, K., Forssell, P. Acta med. scand. 1965,177, 707.

13. Greenfield, J. G. in Neuropathology (by J. G. Greenfield et al.); p. 201.London, 1958.

14. Neal, J. B. Encephalitis; p. 286. New York, 1942.15. Parsons, A. C. Rep. publ. Hlth. med. Subj., Lond. 1922, no. 11, p. 122.

The patients at Friern Hospital differed from those seenin the epidemic in the longer prodromal period beforethey were admitted to hospital, and also in the absence ofpleocytosis in the cerebrospinal fluid. HUNTER and

JONES suggest that they may be dealing with a mildersubacute form, which might also explain why caseswould now present a psychiatric rather than a neuro-logical picture as they did in the 1920s. Today drugsacting on the nervous system are readily prescribed totreat psychiatric symptoms, and even small doses oftranquillisers and antidepressants can in some patientsinduce features of acute or chronic encephalitis. Thus,conceivably, the diagnosis may be further obscured.Moreover, illnesses in which symptoms are many anddisturbing and signs few tend to be referred to thepsychiatrist. He needs to be all the more ready to detectdiseases like encephalitis in which only careful serialexamination may catch the fleeting signs which establishthe diagnosis.

Annotations

75th ANNIVERSARY OF THE LISTER INSTITUTE

THE Lister Institute of Preventive Medicine will markthe 75th anniversary of its foundation on Nov. 9 by anOpen Day at the Chelsea Laboratories and by the deliveryby Lord Florey, o.M., at the Royal College of Physicians,of a lecture entitled " Lister and Modern Medicine ".The Institute arose almost by chance from the work of

a committee formed by the Lord Mayor of London in 1889to discuss the prevention of rabies and to make some publicrecognition of the work of Pasteur, who had by that timetreated, free of charge, some 200 persons from this countrywho had been bitten by rabid dogs. The committee col-lected the sum of E2000 which was presented to thePasteur Institute, but it rejected a proposal to found aclinic for the treatment of rabies in this country. Thecommittee would have been disbanded at this point had itnot been for the persistence of two of its members, Royand Turner, who convinced the other members-amongthem Lister, Horsley, Roscoe, Paget, and Thomas Huxley-that there was a need in England for an institute withaims similar to those of the Pasteur Institute. The com-

mittee, of which Sir Joseph Lister finally became chair-man, recommended that an institute should be established" for the preparation and inoculation of material whichhas been found successful for preventive inoculation andthe carrying out of investigations fitted to increase ourknowledge of the nature of disease producing germs ", andset about collecting funds.The Institute was incorporated on July 25, 1891, as the

British Institute of Preventive Medicine. The site, still

occupied by the Institute in Chelsea, was bought in 1893;the first half of the laboratories was occupied in 1898, andthe second in 1910. Meanwhile in 1893, in order to obtaintemporary accommodation in which to begin work, theInstitute was amalgamated with the College of StateMedicine in Great Russell Street, opposite the BritishMuseum. Scientific work began there in 1894 and wascontinued until the staff moved to the new building atChelsea in 1898. In 1903 the Institute, whose name hadbeen changed in 1899 to the Jenner Institute of PreventiveMedicine to mark the gift to it of funds raised to celebrate

1016

the centenary of Jenner’s discovery of vaccination, wasrenamed the Lister Institute of Preventive Medicine.The preparation of therapeutic sera had begun in 1894,

first at the Brown Sanitary Institute in London (where thefirst diphtheria horse-antitoxin was prepared in Britain)and later at a farm at Sudbury, near Harrow. Finally, in1902 the Institute bought the Elstree estate of 25 acres toaccommodate laboratories for research and the preparationof therapeutic sera, and later of bacterial and virus vaccines.

In the 75 years of its existence the Institute has built upa " tradition of work-laboratory, clinical and epidemi-ological ; and advisory as well as research-in the explora-tory and applied aspects of preventive medicine, often inassociation with other institutions and scientists in Britainand overseas," which is rigorously maintained today. Its

outstanding contributions, mainly in microbiology, experi-mental pathology, biochemistry, and biophysics, are

numerous; many of them are of fundamental importance-for example, the isolation of the coenzyme necessary forthe fermentation of sugar by yeast (for which Harden waslater awarded a Nobel Prize), the discovery of the signifi-cance of phosphorylation in the enzymic degradation ofsugar, and (in the past 20 years) the work on the structureof the blood-group substances on the red-blood-cell sur-face which has reached a point where the gene control ofthe biosynthesis of these glycoproteins can be investigated.The Lister Institute, as an independent research insti-

tution, occupies a unique position among medical researchinstitutes in this country. It has been a school of London

University since 1905 (its present staff includes five

professors, one reader, and seven recognised teachers) andhas trained many PH.D and other students. The Institutereceives no direct governmental financial support: itderives its income from endowments, donations, and saleof immunological products and also (like other academicinstitutions) receives support for some projects from theresearch councils. It has enjoyed a close association withthe Medical Research Council (the nucleus of which it

nearly became in 1913) and derives great scientific benefitfrom three M.R.C. units which it accommodates.The rising cost of research makes it increasingly difficult

in these times for research institutes to maintain their

independence: that some should is important. The ListerInstitute has done so for 75 years, and its record is one ofwhich any institute would be proud. In offering congratu-lations to the Institute on this occasion, we are confidentthat the next 75 years will be as fruitful, and we hope thatit will maintain its sturdy and vigorous independence.

A TEST FOR GASTRIC CANCER?

Hakkinen’s description, in the new Scandinavian

Journal of Gastroenterology,2 of an immunochemicalmethod for detecting carcinomatous secretion in humangastric juice may conceivably offer a simple and reliablemeans of detecting gastric carcinoma at a stage when

radiological change is slight. Essentially, the methodentails the preparation of a rabbit antiserum against anantigen derived from the mucoproteins of gastric juice.Immunodiffusion can then be performed between

antigen and immune serum. Preliminary results withan antiserum prepared in response to antigen obtained

from the pooled gastric juice of 7 patients with gastric1. Hakkinen, I. P. T. Scand. J. Gastroent. 1966, 1, 28.2. To be published quarterly. Annual subscription £4 10s. to Universitets

Forlaget, P.O. Box 307, Blindern, Oslo 3, Norway.

cancer have been promising. All results were positivewhen the serum was allowed to react with samples from15 patients with gastric cancer, but no samples were posi-tive from 24 young healthy controls. In 3 patients withpernicious anxmia 1 apparent false positive was recordedin a person with no radiological evidence of cancer. Furtherinvestigation is clearly required, in particular to deter-mine whether a clear distinction can be achieved between

elderly controls with atrophic gastritis or gastric ulcerand the patients with gastric cancer. Nevertheless, themethod of approach is certainly original.

CRISIS OF CONFIDENCE

A MEMORANDUM 1 " prompted by a crisis of confidencein the hospital service " appeared last week. It was thework of three consultants and three junior hospitaldoctors 2 instructed on Sept. 3 by the Central Consultantsand Specialists Committee of the British Medical Associa-tion to draw up

" a charter for all hospital doctors ". In

less than twenty years, the document declared, theGovernments of this country had reduced a noble pro-fession to a state of seething unrest; and it then outlinedthe main causes of this dissatisfaction among hospitaldoctors.The nation had not provided the money to realise the

concept on which the National Health Service was

founded. Vast new sums were needed for the hospitalservice, and if the Exchequer was unable to provide themthe Government’s duty was to investigate alternativesources and publish its findings. The present hospitalbuilding programme would never build sufficient hospitalsquickly enough. The basic requirements for hospitalconstruction were now well known, and it was two yearssince the profession agreed to the principle of standardisa-tion in the interests of speed. Many new hospitals could bebuilt now, quickly and efficiently, along these lines." This is an emergency situation and should be treated assuch."

Consultant cover was already quite inadequate to fulfilthe most urgent needs of the hospital service. In the

present critical situation, the authors of the memorandumbelieved that many senior registrars, including some whohad not yet completed their normal tenure, had the neces-sary experience to fill consultant vacancies immediately.The National Health Service must make a major con-

tribution to postgraduate training and research; and con-tractual time must therefore be provided to allow for studyin the junior grades and teaching in the senior grades.Junior medical staff were perturbed because their workhad been increasingly related to service needs, so that theirtraining had been overshadowed. This situation had con-tributed to the increasing loss of doctors by emigrationand to the growing dependence of the hospital service onoverseas graduates. " It is folly for any national healthservice to be thus dependent on a supply of medical man-power which could at any time be cut off at its source."

Establishments in registrar and senior-registrar gradesshould be directly related to future consultant require-ments. A post not recognised as an approved training postshould be designated as an associate registrar post, with ahigher salary to take account of the greater service com-1. Br. med. J. Oct. 29, 1966, suppl. p. 171.2. Mr. H. G. Hanley (chairman), Dr. J. R. Bennett, Dr. E. A. Harvey

Smith, Mr. W. S. Lewin, Dr. R. M. Mayon-White, and Dr. T. HTaylor.