Table 3.

Miscellaneous observations of clinical features and treatments

Clinical domain	Observations
Motor	Early symptoms: Often the first symptom of the more chronic phase of the illness was unilateral stiffness or a reduced arm swing, as in one patient whose first symptom was that he would travel round in circles when rowing, or another who had difficulty playing the piano. However, musculoskeletal pain was also a very common initial symptom. Insight: Many patients had insight into their parkinsonism, recognizing that they were moving more slowly and that their speech had become quiet and monotonous. One patient with stupor and catalepsy in acute encephalitis lethargica improved and stated she had ‘felt like starch’. Movement during sleep: Tremor was noted in several cases to stop during sleep. However, there was one patient who had abnormal stereotypic ‘piano-playing movements’ during sleep. Kinesia paradoxa: One patient, who usually held himself ‘quite motionless’ and exhibited marked bradykinesia, was able to catch another patient who was falling ‘in the burst of the moment’. Another patient, who was usually unable to stand or undress himself, was once called ‘spindle-legs’ by his father and managed to leap up from his chair to hit him. Several patients were able to run better than walk, while one found it easier to pick up heavy objects than light ones. Bizarre intermittent movements: One patient with ‘fidgeting movements’ would find that each evening, he would fling his limbs about wildly and start running and turning somersaults. Another’s gait was shuffling, but every few minutes would pirouette two or three times.
Oculogyric crises	Precipitants: Emotions—both positive and negative—were cited on several occasions as precipitants and in one patient it was noted that a crisis could be terminated if he could be distracted. One patient’s crises were precipitated by bending down. Psychiatric symptoms during crises: One patient described features of depersonalization with a ‘feeling of unreality’, stating that he knew what to do but did it ‘unconsciously’ and ‘automatically’. Several patients had forced thinking or obsessional thoughts, such as one patient who felt compelled to think of words 7–9 letters long or another who would have to spell out the same word repeatedly. Others described feeling worried or hopeless during the attacks.
Sleep	Hypersomnia: The severity of hypersomnia was very stark in many cases, such as one individual who fell asleep and awoke 10 weeks later and another who was in such deep sleep that she was blistered by a hot water bottle. One patient would fall asleep so easily that she would fall downstairs and on one occasion when she fell asleep in front of the fire was seriously burnt.
Psychiatric	Socially unacceptable behaviour: Several patients had a severe change in their personality and began engaging in behaviours that would previously have been alien to them. Four started engaged in kleptomania and more generally some were noted to have lost the ability to perceive right from wrong. Two patients started making sudden unprovoked attacks, one throwing knives at other patients. Impulse control behaviours: A couple of patients had typical features of obsessive-compulsive disorder. Two were noted to have compulsive nose-picking. One patient found himself unable to stop repetitive behaviours like polishing shoes or beating eggs, despite a desire to. The behaviours were distinctly ego-dystonic. Suicide: Two patients were noted to have died by suicide, though the cause of subsequent death in the period after hospital admission was rarely recorded. In addition, one patient reported suicidal ideation and another had attempted suicide. Difficulty in initiating actions: Several patients were noted to have extreme difficulty in initiating actions, such as one who took ‘a whole day to write a letter, nerving himself up to write one word at a time.’ Affect: While a few patients were noted to have difficulty expressing their emotions despite a wish to do so, uncontrollable emotional expression seemed more common. Several patients were noted to laugh uproariously or break down in tears with very little emotional precipitant.
Speech	‘Phonia paradoxa’: The classic hypophonic, monotonous speech of parkinsonism was extremely common, but in several patients such speech abnormalities were noted to be corrected when the patient sang, shouted or spoke in public.
Other clinical features	Dysphagia: This was a surprisingly common clinical feature and often appeared even in relatively mild cases. Visual distortions: Blurred vision and diplopia were common, but more intriguingly one patient with diplopia in the acute illness saw one of the images upside-down. Another patient in the acute illness could only see half of an object, sometimes the right, sometimes the left.
Treatments	Medical: By far the most common treatments used were anticholinergic medications. Other treatments included parathyroid extract, adrenaline (to regulate the sleep–wake cycle) and even malaria therapy. Surgical: Surgical approaches were occasionally used, including one operation by Sir Percy Sargent to cut some of the right dorsal cervical and thoracic roots to relieve tremor. In another patient, fingers that were in fixed flexion were amputated. Other treatments: One patient underwent X-ray treatment to the parotid gland for hypersalivation. Dr Gordon Holmes conducted daily psychotherapy with a patient for 2 months with the aim of treating her oculogyric crises.