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Similarly, I would submit, ’’ Economo’s disease " is abetter designation than "

encephalitis lethargica,"where neither lethargy nor evidence of encephalitis isessential to the diagnosis ; it entails no misapprehen-sion ; in fact, it avoids any.As Prof. A. J. Hall has well said, in his Lumleian

lectures, " the name encephalitis lethargica surviveschiefly from reasons of sentiment, since it is the oneselected by von Economo. By retaining it we paytribute to his remarkable work ; a work renderedeven more remarkable by the fact that it was carriedout at the height of a great war, under all thedifficulties which that involved." I share this sent,i-ment, but think it would be better expressed by givingto the disease the name of its discoverer. WhenFreiherr von Economo chose the present name, itcovered the known facts ; now he would probably bethe first to admit it no longer does so. His name is sofamiliar in connexion with the disease that the oneimmediately recalls the other. I believe the adoptionof the term " Economo’s disease " would tend to clearthe path of further observation.

I am, Sir, yours faithfully,Exeter, April 17th, 1923. W. GORDON.

A CASE OF PARKINSONISM WITHOUT INITIALSYMPTOMS OF ENCEPHALITIS.

To the Editor of THE LANCET.SIR.—Prof. A. J. Hall has referred in his recent

Lmnleian lectures to the clinical differences betweenParkinsonism and the pre-senile form of paralysisagitans. The following case illustrates some of thepoints in this connexion. The patient, a marriedwoman of about 35. first came to me as an

out-patient at the Miller Ilospital in March ofthis year. She had been treated for some monthsfor indigestion, she always felt tired, took littleor no interest in things, and merely wanted to sitabout. Her general appearance was characteristicof the Parkinsonian type of disease; she had a

mask-like expression. and the typical slow progres-sion and stiff attitude of body with the arms held alittle forward, the elbows being slightly flexed. Therewere none of the movements commonly seen in theordinary pre-senile type of paralysis agitans, and theclinical picture suggested the Parkinsonian sequelæof lethargic encephalitis. I went carefully into theprevious history expecting to get a story of an attackof so-called influenza, but was unable to elicit anaccount of any definite febrile period. I saw thepatient again at my house together with Prof. Hall.She had not been conscious of any visual disturb-ances such as might have suggested ophthalmoplegia.The indigestion of which she had complained beganapparently about a year ago, a point of some import-ance, in connexion with the seasonal incidence of thedisease. She slept well and could go to sleep easilyat any time that she liked, but there was no evidencEof her having had any involuntary lethargic periods.On examination the first and most obvious signs werEthe rigidity of the upper limbs, the general postureand the mask-like features and extremely fixec

expression. The pupils reacted to light and accommodation, but the latter reaction was sluggish and th(accompanying convergent movements of the eye;were weak and ill-sustained. There was no trUt

nystagmus, but slight nystagmoid movements and acertain weakness were apparent on extreme lateramovement. There was evident difficulty in fixingobjects. The fundus oculi appeared normal on botlsides. When the patient was asked to open the han(quickly after making a fist, there was some hesitationand slowness in extension of the fingers. A slighfine tremor was observed when the arms wer’

extended. There was a definite fine tremor of th,tongue and slight hemi-atrophy affecting the left sideSome tremor of the lips was also noticed. The knee

jerks were easily obtained and were brisk on both sidesHer general health was good, the indigestion havin;by this time disappeared. She had had amenorrhoE.

for about three months, but the periods had recentlycome on again ; she did not think there had been anyquestion of pregnancy.Apart from the question of age and the absence of

the characteristic pill-rolling movements, the earlyand 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 insidiousL onset and the complete absence of evidence of theL 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 Iam 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 acutei period of the disease may be so short as to be forgottenr by patients, a careful review will usually reveal some

feature or features which enable one to trace the dateof onset with fair accuracy. It is interesting to notethat the only previous symptoms mentioned by thisparticular patient were those of dyspepsia, and it isrecognised that gastro-intestinal disturbances maysometimes occur as early symptoms of lethargic

encephalitis.-I am, Sir. yours faithfully,MAURICE DAVIDSON.

Wimpole-street, W., April 20th, 1923.

THE LIFE-HISTORY OF THE TAPEWORM,HYMENOLEPIS NANA.

’ To the Editor of THE LANCET.’ SiR,—In your issue of 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 wasintended, and that there is nothing in the publishedreport (Proc. Zool. Soc., 1911) to suggest such. As thestatement referred to occurred in a review of recentcontributions to medical helminthology written byme for the Bulletin, I may be allowed to say that theclaim attributed to Dr. Nicoll and Prof. Minchinrests upon the authors’ abstract published by theZoological Society, November, 1910, which states

i 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-. worm of man." " The chief interest of the discoveryi 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 whichDr. Nicoll complains.—I am, Sir, yours faithfully,

R. T. LEIPER.London School of Tropical Medicine, Endsleigh-

gardens, 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. DavidSmith takes me to task for assuming that Hofmann’sbacillus is non-pathogenic. In the work in questionthe majority of the organisms came from boyswithout symptoms, and these strains were presumedto be non-pathogenic. However, I should not like tomaintain that bacilli with a morphology of theHofmann type can never cause symptoms. Patho-genicity is an attribute that seems very variable, andunder the influence of a suitable environment it isquite conceivable that certain strains of Hofmann-like bacilli are sometimes pathogenic. Many timesin sore throats, not resembling diphtheria, I havefound Hofmann bacilli as predominant organism,yet in the light of my own experience I have hesitatedto ascribe an ætiological significance to this fact.

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These bacilli are also frequently associated with truediphtheria bacilli in thé throats of both carriers andcases. In the former they may prevent satisfactorydemonstration of the toxic diphtheria bacilli, but inactual cases of diphtheria it is very rare to be unableto isolate the toxigenic bacilli from the admixturewith atoxic Hofmann bacilli.- In -the absence of information as regards thevirulence of the bacilli from Dr. Smith’s cases ; from

the fact that some of the patients responded so

promptly, to specific diphtheria antitoxin ; that theclinical condition suggested diphtheria, and yetbacilli which morphologically resembled toxicB. diphtherice could not be demonstrated, it seemsquite possible that these patients were infected witha toxic diphtheroid of the Hofmann type. Theevidence, however, is far from absolute; and -even ifit were absolute, it does not alter the probabilitythat usually Hofmann’s bacillus is harmless. Dr.Smith’s interesting series of cases is also strong con-firmation of the opinion expressed in my report, that,whatever the bacteriological findings may be, anti-toxic serum should be given to any patient whoseclinical condition suggests diphtheria.

.

I am. Sir. vours faithfully.R.N. College, Greenwich, S. F. DUDLEY.

ANNULAR SHADOWS IN THE RADIOGRAM.- To the Editor of THE LANCET.

SIR,-In the course of some notes on X RayExamination of the Chest, which appeared in THELANCET of March 17th (p. 535), we expressed theopinion that radiogram No. 6 showed a small circularcavity at the apex of the left lung. Some of yourcorrespondents take the view that this was not acavity, but a pleural annular shadow. We thereforetake this opportunity of giving more in detail ourreasons for thinking this was really a shallow cavity,bounded by a ring of fibrous tissue.1. There can be no doubt clinically, and all medicalmen who have had him under observation agree, thatthis’patient has tuberculosis of the lungs, although henow has no sputum or other physical signs.

2. There must, therefoie, be a tuberculous focus inhis lungs, and the only evidence that exists of this isat the apex of the left lung, where we are of theopinion that a shallow cavity is present.

3. The X ray appearance of this annular shadow isconstant, and is present in several radiographs whichhave been taken at long intervals. It is to be seenon the fluorescent screen, and is as plainly visible fromthe front as from the back..

AA-e are. Sir. vours faithfully.

Montana, Valais, Suisse, April ]6th. PERCY G. SUTTON.

L’AFFAIRE SPAHLINGER.’1’0 the Editor of THE LANCET.

SIR.—I am from Australia commissioned to investi-gate for the Government of Victoria the Spahlingertreatment for tuberculosis. I thought it best to gostraight to Switzerland, and before seeing Mr.Spahlinger I went up the mountains to investigate histreatment in action in a sanatorium. I then came downand spent some days with Mr. Spahlinger at Genevaat his.wonderful laboratory and experimental farm6f’fiors’e-s, cows, goats, &c. During this time I was’constantly examining patients who were being or

had been treated along Spahlinger lines-comparingold and present conditions, examining old and recentX ray pictures of chests, listening to histories, &c.I then read the reports of a number of cases in journalsand in manuscript ready for publication that hadreceived this treatment at the hands of chestmenof repute. I understand I have yet to see cases inEngland that had undergone this treatment.Any further evidence I feel sure will only confirm

me in reporting to my Government that HenrySpahlinger’s vaccine and serum treatment in tuber-culoses stands by itself, and that the medical pro-

fession should lose no time in taking a definite standin this matter. But the production of these remediesand prophylaxins is almost at a standstill. TheSpahlinger family, once in affluent circumstances,are now almost penniless. They have spent all theyhad in this self-imposed search for potent anti-tuberculous vaccines and sera. Henry Spahlingerloathes publicity, lives in an atmosphere of patientand cheery altruism, has spurned repeated offers fromfirms and private individuals to

" commercialise " hiswork—offers that would have resulted long ago inretrieving his family’s fortune.

There is still -another serious matter. The longstrain of work and debt-carrying is beginning to tell onMr. Spahlinger. There have been for some timeunequivocal signs of nerve depletion. Truly thereare the makings of a tragedy here.

I am, Sir. vours faithfullv.

I’ London, April 17th, 1923. J. F. MACKEDDIE, M.D.

To the Editor of THE LANCET., SIR,—I first became interested in the work of Mr.Henri Spahlinger, of Geneva, by reading the communication presented to the Paris Academy ofMedicine. Unfortunately, I found it impossible atthat time to obtain the vaccines and sera, the stockhaving been exhausted by the experiments carried outin London. In 1918 Dr. Stephani, whom I considerto be one of the highest authorities on tuberculosis inEurope, informed me of the remarkable results whichhe had obtained with the Spahlinger treatment, invitedme to experiment with it, and supplied me with serum.Shortly afterwards I met Mr. Spahlinger, who explainedto me the principles of his method and the ideas whichhad guided him in his research work. The lattercoincided in every way with my own ideas.

I used the antitoxins and bacteriolysins in a certainnumber of cases under experimental conditions whichwere, however, somewhat unfavourable, since inseveral instances injections had to be postponed forlack of serum. In spite of this fact, my results werevery encouraging. In every case treated, whether ofmedical or of surgical tuberculosis, the sera exerted avery favourable curative action. With the bacterio-lysins I regularly obtained complete drying-up of tuber-culous fistulæ after four or five injections. My testsbrought me to the conclusion that Mr. Spahlinger’sresearches are extremely interesting. In my opinionthey constitute the most rational direction in whichsearch has been made for a specific treatment of tuber-culosis. The combination of antitoxic sera andbacteriolytic sera enables one of the most importantstumbling-blocks of this specific therapy to be avoided.My results allow me to state that this method is thebest means of treatment of medical and surgical tuber-culosis, and I shall gladly associate myself with every-thing that may be done to assist Mr. Spahlinger topopularise the use of his very promising method.The following is a brief note of a case under my own

observation :-In July, 1918, a small tuberculous nodule appeared at

the head of the left epididymis, increasing in four weeks tothe size of a haricot bean. Dr. Calot and Prof. Sebileauadvised against any surgical intervention. The conditionpersisted until March, 1919, when the nodule again beganto grow, extending along the epididymis until in August,when the head was completely involved, the tumour wasthree centimetres long and the thickness of the littlefinger, capping the testicle ; there were also several isolatednodules on the latter. In September a small nodule appearedon the right testicle. In October a left hydrocele developed,attaining a capacity of 200 c.cm. At the beginning ofNovember 10 e.en-1. of Spahlinger’s bacteriolysin No. 5 weregiven daily- by the mouth for three days, and resulted incomplete disappearance of the liquid contents of the hydrocele.Ten days afterwards, alternate injections of six 2 c.cm.ampoules of polyvalent bacteriolysins M.1 and M.2 weregiven, followed after ten days’ interval by six similar injec-tions. During the following three weeks’ rest generalisedtroubles appeared-fever, cramp, general fatigue, and lossof appetite—which persisted for a fortnight ; at the sametime the tumour became progressively smaller, so that aftera ’fortnight the testicle was left entirely smooth, with notrace of tuberculosis, and the same size as the other, from