CASE STUDIES TWO CASES OF PROBABLE POST-ENCEPHALITIS
time has a disease received so much has epidemic encephalitis since its rediscovery in modern little more than a decade ago. A recent report on the study
Never perhaps in attention
times
a
so
short
a
as
of this condition contains a bibliography of more than four thousand titles. Most of this work, of course, is written from the medical point of view. So obscure in its initial attack, so readily masked by other more common diseases in conjunction with which it seems at times to occur,
so multiform in its subsequent symptoms which simulate almost any disease of the nervous system, this disease is a matter of serious concern to both physician and clinical psychologist. Relatively a very small amount of the literature 011 this subject is devoted to the psychological aspect of the disease. Recently in the Psycho-
logical Clinic I examined and had an opportunity to observe two boys whose cases are of interest in this connection. This is particularly so since in the one case the diagnosis of the initial attack of encephalitis was only probable since it occurred in conjunction with another condition.
In the other
case
the initial attack
was never
at all because the parents did not consider the boy ill to require medical attention. I believe both these boys were
diagnosed enough
at the time of their examination
suffering
from the after effects of
epidemic encephalitis, and moreover, that more children are suffering from the sequela} of this disease than is commonly realized. Because the disease is comparatively new, the differential diagnosis extremely difficult and the initial attack often very mild in nature, the medical history in a given case is not always accurate. The first boy, whom we shall call John, was seven years old. He was brought by his father to the Psychological Clinic because of retardation in school. John had spent two terms in kindergarten and had just been promoted to the First Grade a few days before his coming to the Clinic. His parents and his former teacher were very doubtful of the probability of John's progress in the First Grade. There were three other boys in the family, all of them, according to the report, of superior ability. John's general retardation was expressed by the father when he said that a younger brother four years of age was more
superior
letters of the
to John in many ways and
alphabet although
he had
never
already knew taught.
been
166
THE PSYCHOLOGICAL CLINIC
John's birth was normal. He was walking and talking and had become clean by two years of age. When four years old he had an attack of acidosis which the physician thought might be "sleeping sickness." The child slept for three days, awaking at intervals for only a few minutes. During this period he ran a very high fever. When John recovered from this illness he had to learn to walk all over again. He has been much retarded since then, but during the last six months the parents believe they notice some improvement. He is stubborn and disobedient, very difficult to control, and does not pay much attention to commands. During the examination he was highly distractible, a condition of which his parents complain in trying to teach him. His attention drifted from one object in the room to another, and only with difficulty was it brought back to the problem at hand. He fidgeted around in the In looking chair continuously and asked irrelevant questions. head to if had diffione as he his side turned at he closely anything His head was his in eyes. asymmetrical, the coordinating culty left side being more fully developed than the right. His general reactions were infantile, and his speech still shows some infantile mutilation. John's behavior at home and the difficulty experienced in controlling him as described by the father, and his lack of concentration and persistence in the psychological examination are of course
typical of post-encephalitis.
The results of the examination indicate very inferior competency. John's audito-vocal memory span was three which is very poor in a seven-year-old; he was unable to read numbers for the visual span and he did not comprehend the reverse. His Intelli-
Quotient on the Stanford-Binet was 67. He failed the WitCylinder Test which is completed by fifty per cent of sixyear-olds. On the basis of this examination John would very likely be diagnosed as feebleminded. We can only say that his behavior at the present time is that of a feebleminded boy, and perhaps he is feebleminded. He requires educational treatment of a very specialized kind, first to develop his control and concentration of attention, and second to increase gradually the complexity of his intellectual organization and his efficiency of production. gence
mer
is
He should be re-examined in a year. The parents believe he improving. This can be determined by another examination. If
CASE STUDIES
167
he continues to improve and receives proper educational treatment he may be restored to normal competency. The second boy, Henry, was ten years old at the time of his examination. In his case epidemic encephalitis was never diagnosed and the possibility of his having had the disease is only suggested by the history. Henry walked and talked by the age of eighteen months; he became clean at two years. At the age of four his parents noticed a great change in the boy. For a time he seemed
entirely lifeless. As his mother expresses it, he would sit in a chair "just like a coat that had been thrown there." After this period Henry never seemed to be the same. Nocturnal enuresis began and was not stopped until eight years of age. Henry has never gotten along well in school. Since the second grade he has had private to his regular school work. At the present time he is in the Fourth Grade, has Second Grade proficiency in reading and spelling, Third Grade proficiency in arithmetic. His reactions are infantile and he prefers to play with children four or five
tutoring in addition
years old. In the psychological examination Henry does somewhat better than John. His audito-vocal memory span is five forward and three reverse; his Intelligence Quotient is 89. On performance tests he does quite well. His performance on the Dearborn formboard was superior to that of eighty per cent of Fifth Grade boys. He is
generally more proficient in mechanical efforts, likes to play with mechanical toys and enjoys manual training. Henry is of interest in that he shows none of the behavior problems so frequently found in post-encephalitis. He is quiet, amenable, well behaved. The prognosis for successful adjustment at a low intellectual level and a simple occupation is favorable. If he had epidemic encephalitis he has escaped with rather more of his native ability than is usually the case. Miles Murphy
time has a disease received so much has epidemic encephalitis since its rediscovery in modern little more than a decade ago. A recent report on the study
Never perhaps in attention
times
a
so
short
a
as
of this condition contains a bibliography of more than four thousand titles. Most of this work, of course, is written from the medical point of view. So obscure in its initial attack, so readily masked by other more common diseases in conjunction with which it seems at times to occur,
so multiform in its subsequent symptoms which simulate almost any disease of the nervous system, this disease is a matter of serious concern to both physician and clinical psychologist. Relatively a very small amount of the literature 011 this subject is devoted to the psychological aspect of the disease. Recently in the Psycho-
logical Clinic I examined and had an opportunity to observe two boys whose cases are of interest in this connection. This is particularly so since in the one case the diagnosis of the initial attack of encephalitis was only probable since it occurred in conjunction with another condition.
In the other
case
the initial attack
was never
at all because the parents did not consider the boy ill to require medical attention. I believe both these boys were
diagnosed enough
at the time of their examination
suffering
from the after effects of
epidemic encephalitis, and moreover, that more children are suffering from the sequela} of this disease than is commonly realized. Because the disease is comparatively new, the differential diagnosis extremely difficult and the initial attack often very mild in nature, the medical history in a given case is not always accurate. The first boy, whom we shall call John, was seven years old. He was brought by his father to the Psychological Clinic because of retardation in school. John had spent two terms in kindergarten and had just been promoted to the First Grade a few days before his coming to the Clinic. His parents and his former teacher were very doubtful of the probability of John's progress in the First Grade. There were three other boys in the family, all of them, according to the report, of superior ability. John's general retardation was expressed by the father when he said that a younger brother four years of age was more
superior
letters of the
to John in many ways and
alphabet although
he had
never
already knew taught.
been
166
THE PSYCHOLOGICAL CLINIC
John's birth was normal. He was walking and talking and had become clean by two years of age. When four years old he had an attack of acidosis which the physician thought might be "sleeping sickness." The child slept for three days, awaking at intervals for only a few minutes. During this period he ran a very high fever. When John recovered from this illness he had to learn to walk all over again. He has been much retarded since then, but during the last six months the parents believe they notice some improvement. He is stubborn and disobedient, very difficult to control, and does not pay much attention to commands. During the examination he was highly distractible, a condition of which his parents complain in trying to teach him. His attention drifted from one object in the room to another, and only with difficulty was it brought back to the problem at hand. He fidgeted around in the In looking chair continuously and asked irrelevant questions. head to if had diffione as he his side turned at he closely anything His head was his in eyes. asymmetrical, the coordinating culty left side being more fully developed than the right. His general reactions were infantile, and his speech still shows some infantile mutilation. John's behavior at home and the difficulty experienced in controlling him as described by the father, and his lack of concentration and persistence in the psychological examination are of course
typical of post-encephalitis.
The results of the examination indicate very inferior competency. John's audito-vocal memory span was three which is very poor in a seven-year-old; he was unable to read numbers for the visual span and he did not comprehend the reverse. His Intelli-
Quotient on the Stanford-Binet was 67. He failed the WitCylinder Test which is completed by fifty per cent of sixyear-olds. On the basis of this examination John would very likely be diagnosed as feebleminded. We can only say that his behavior at the present time is that of a feebleminded boy, and perhaps he is feebleminded. He requires educational treatment of a very specialized kind, first to develop his control and concentration of attention, and second to increase gradually the complexity of his intellectual organization and his efficiency of production. gence
mer
is
He should be re-examined in a year. The parents believe he improving. This can be determined by another examination. If
CASE STUDIES
167
he continues to improve and receives proper educational treatment he may be restored to normal competency. The second boy, Henry, was ten years old at the time of his examination. In his case epidemic encephalitis was never diagnosed and the possibility of his having had the disease is only suggested by the history. Henry walked and talked by the age of eighteen months; he became clean at two years. At the age of four his parents noticed a great change in the boy. For a time he seemed
entirely lifeless. As his mother expresses it, he would sit in a chair "just like a coat that had been thrown there." After this period Henry never seemed to be the same. Nocturnal enuresis began and was not stopped until eight years of age. Henry has never gotten along well in school. Since the second grade he has had private to his regular school work. At the present time he is in the Fourth Grade, has Second Grade proficiency in reading and spelling, Third Grade proficiency in arithmetic. His reactions are infantile and he prefers to play with children four or five
tutoring in addition
years old. In the psychological examination Henry does somewhat better than John. His audito-vocal memory span is five forward and three reverse; his Intelligence Quotient is 89. On performance tests he does quite well. His performance on the Dearborn formboard was superior to that of eighty per cent of Fifth Grade boys. He is
generally more proficient in mechanical efforts, likes to play with mechanical toys and enjoys manual training. Henry is of interest in that he shows none of the behavior problems so frequently found in post-encephalitis. He is quiet, amenable, well behaved. The prognosis for successful adjustment at a low intellectual level and a simple occupation is favorable. If he had epidemic encephalitis he has escaped with rather more of his native ability than is usually the case. Miles Murphy
