The Asylum journal of mental science
The Asylum journal of mental science.
Bia toa ty Coe Seen wah ATO eS so Pr PS Re ac RMU INEMIN GS ey Fes UN get Tana eR Ng BP rth OU oh iis Bee aie a Gee ae : boyy Hea een ate ee Sint afer ioe i SWRA hormones Pe : Regie Yn cook Masia RS OE ERT oT : Sacer i occa SsinTst sta, Gene e aN EN inh Beer tee or 5 koh ane Oe a Sai al PSS Pa Rr OS 1 er Oy 3 Pi) on AN ie 7 c Ware ® , . z - é = pac $ PEN te es, a, Ope SCONE eS RSS tr eee ; oReah Nes = ee ¥ Payer ac é Ns EN res) ae = - fi : Bis Di ae ay oF fens, #680 ances eee ee aN ecewnsae 4 ait at Mee git sit Fy Gr a ee Crane et we 3 ti , SSE ys, aRRGN | < a oenets opt a “3 ‘ : Pee es Bo Pe AOE Neate Tw a Boom sel Kara hy “Si f 3 ee ate foe ben Pom a ai re id a Pa EN ao a ae = ke a : , pyrene tie gute eae beter sieef aseaa era ws a RR ee “ . Z e 4 < SMe rz 3 a x 1 Pap con So apap: PS ae oS RET K Merete a stat, BENE : . rm 3 : : Se te : . Sd RF ea hae 4 nat _ [Pie aa, ee eet cont aS Oe aes 2 ¥ 2 - Tee PL pred eesti mea. vies ian a poe See, os ic Ne ee Pe se WER ; eis Ree Rages aan fincas enn. : Da. ; ; te ce tae (ocean as rmaye earn Pe, Be es ; Fee te Ta gta Oi De, eat e ee Wie er - aa a Ati ahi ita Fm on : s “ 7 é oa e (Aah gS 7, ee ar i ee Sere SSS Fr cane : tach a ye en ve Set OED raat <ee ‘ ‘fe ¢ a Bia — Pag OI et ry, cage : arse: = Oe ON whe Bh te gy 3 7 , oa sae a anease ce 2. = “ s = oe rer “i A re Se ir ened eee pence Re é Rea me te Aten Pes AUS Se OE, pion. et&igs : =. z a PEA Ie soe ee ae ee ation oes Be i Fn Fushi sc oaks eee es in Pogice oe PN € ars ¥ % Aa bes pene i. a ‘i nd pi f at’. oa FONG fiery Na UI ON A os F 2 ve Sia se, Pages = a Preys mag a E ipa e te ord: ‘ hy mi as ee bts = Fr ee ee a Re Stake. eras DR ey Shane ¥ - i. \ 5 P = Pe a So i. bs + PRS MONS te ae ng SA " ae z nerbe en: er Be he as ; y ae te cn SON cat ege Fag OR : ais ie PO te ae “ re A ; ~ * : ; ; SAD ee ieee on “ ee eee en BS Pe A ren =. z : reas ye" Sat Sf ae. 3 mya, a he oe ’. ine iy i z y Str isles IT vam Pee PSE el PO feng RO uae g NEE vet = ice : : ae eI eal ears ; ty ere Serene ie Slee “ie eS pots i Re waa eh ™” elgg nat ee pephiitina: (am ghee. ¥ tO a ee NE zi aga & ge a9 a 3 3 gh, 2 7 “. * * a SO Re gen eg, ee ser he ‘ : ee : : So ae oe wala, Th PERV aie OFS a of Fee Komenes sagen : ft heact ; ‘. ong = ‘ Saat ating es id nae Bae Sense 2 SO re on ied — rat oe Pees Piped a= sFe a ¥ Ray ET Re one Oe % oa = PF rage ee ~ ae na MAU Pe et Ftd ; 7 <—e ae 4 < ; ¥ i . yi pee '. Saye Ty -« gt ? iy + oe +) tier { % + + ca * ‘ : ’ @. ie ¢ ym : , > es ; Bi ; i ek oe & ’ : 7. loa , 2 + 7 sg i. Ss ay pe c ; + 2 s & : : - : . rs a - is * . dae * 1. es : : a, 1 Fi i A 4 ; ‘ j ;. ae Shorr 7 pe j 7 :. ‘ s ;. ; Woe ; : ; i J + i Py 7 Fe. “* ae ? a ¥ ’ - to * % a r ™, y ee ee 4 ol 2 - ‘ ¥ - b ; * # ‘ * > . . é , oor a ‘ at i ; ms ee 7 : =, ra % a : aa ne = - * 7, bs iL 1 r e ' ~ A :. , 7 “3 ¢ j ‘ 7 ' % ‘ . + c : > ‘ ‘ + i + 7 f “ -. : 7 A § , 7 . = co" ‘ ‘ 2 2 7 ae & s i ‘a a : : ; y “ wey : “i tear j ' A ¥ «* 3 - ’ P a An ' ue ‘ ss ry 7 g % J s ee POURNAL OF MENTAL SCIENCE EDITORS : Henry Rayner, M.D. A. R. Urquhart, M.D. Conolly Norman, F.R.C.P.I, ASSISTANT EDITORS: | J. Chambers, M.D. J. R. Lord, M.B. bel. XN. LONDON Peace. CHURCHILL, 7, GREAT MARLBOROUGH STREET, MDCCCC, “In adopting our title of the Journal of Mental Science, published by authority of the Medico-Psychological Association, we prcfess that we cultivate in our pages © mental science of a particular kind, namely, such mental science as appertains to medical men who are engaged inthe treatment of the insane. But it has been objected that the term mental science is inapplicable, and that the term mental physiology or mental pathology, or psychology, or psychiatry (a term much affected by our German brethren), would have been more correct and ap- propriate ; and that, moreover, we do not deal in mental science, which is pro- perly the sphere of the aspiring metaphysical intellect. If mental science is strictly synonymous with metaphysics, these objections are certainly valid; for although we do not eschew metaphysical discussion, the aim of this JOURNAL is certainly bent upon more attainable objects than the pursuit of those recondite inquiries which have occupied the most ambitious intellects from the time of Plato to the present, with so much labour and so little result. But while we admit that metaphysics may be called one department of mental science, we main- tain that mental physiology and mental pathology are also mental science under a different aspect. While metaphysics may be called speculative mental science, mental physiology and pathology, with their vast range of inquiry into insanity, education, crime, and all things which tend to preserve mental health, or to pro- duce mental disease, are not less questions of mental science in its practical, that is in its sociological point of view. If it were not unjust to high mathematics to compare it in any way with abstruse metaphysics, it would illustrate our meaning to say that our practical mental science would fairly bear the same rela- tion to the mental science of the metaphysicians as applied mathematics bears to the pure science. In both instances the aim of the pure science is the attainment of abstract truth; its utility, however, frequently going no further than to serve as a gymnasium for the intellect. THE) JOURNAL OF MENTAL SCIENCE [Published by Authority of the Medico-Psychological Association of Great Britain and Ireland. | Noetogie a cs JANUARY, tIg00. VoL. XLVI. Part I.—Original Articles. —— ee Abstract of a paper on the Necessity for Isolating the Phthisical Insane. By ERIC FRANCE, M.B., B.S., Second Assistant Medical Officer, London County Asylum, Clay- bury. Followed by a discussion by Sir WILLIAM BROADBENT, Bart., Sir J. CRICHTON-BROWNE, Prof. CLIFFORD ALLBUTT, and others, at the General Meeting of the Medico-Psycho- logical Association, London, 9th November, 1899. I HAVE no intention of tracing the history of tuberculosis in asylums through the official obscurity of the past fifty years. This point has already received careful investigation at the hands of Dr. Crookshank in the admirable essay he has recently published; (") nor are we here concerned with any comparison between the mortality from tubercle among asylum inmates and the mortality from tubercle among the general population, inasmuch as deductions drawn therefrom are liable, among other errors, to those fallacies which occur when two communi- ties whose environment and susceptibility differ are compared as regards the mortality of any particular disease. What we are concerned with, I take it, is the position which tubercular mortality holds in asylums at the present time, and the means to be adopted to remedy this state of things. I have therefore to lay before you very briefly some of the salient XLVI, I 2 ISOLATING THE PHTHISICAL INSANE. [Jan., 1900, points with regard to the incidence of tubercular disease among the insane and its prevalence compared with other diseases ; to urge the necessity for some means being taken to reduce that prevalence ; and finally, to suggest some scheme by which such an end might be attained. The tables and charts herewith presented show the mortality from tubercle as compared with some of the most fatal diseases in asylums. The figures are compiled from the blue- books of the Commissioners in Lunacy, and from the annual reports of the Asylums Committee of the London County Council, referring to the years 1895—6—7-—8 inclusive. It may be remarked that 1895 was the first year in which the returns of causes of death, as shown in the blue-books, were sufficiently comprehensive to warrant comparison with subse- quent years. The charts are drawn absolutely to scale. It is gravely to be feared that the figures I have quoted are very far from accurately representing the number of patients actually suffering from phthisis in the asylums of England and Wales. As it is aS from a statistical point of view, to return more than one cause of death for each patient, it is easy to understand that evidence of active tubercle may be found in many patients who are shown as dying from some other disease. , In Claybury Asylum and at Colney Hatch and Cane Hill, where the post-mortem records have been kindly examined for me, a marked disparity exists between the statistical returns and the number of cases in which active tubercle was found at death, as is shown in the following table: Certified deaths Active tubercle 1898. from tubercle. found P.M. Claybury ae Re 49 Colney Hatch “vam26 ei: 41 Gane, Hall Hew LS ah a2 67 Tr2* * These figures do not include 10 doubtful cases. It will thus be seen that at these three asylums the number of patients dying with active tubercle, as compared with those certified as dying from this cause, practically stand in the pro- portion of 2 to I. 3 Pe DERS AND CHARES Elucidating the paper by Dr. Eric FRANCE. [Jan., ISOLATING THE PHTHISICAL INSANE, | zi gSI 9fz | vse b£o 611't zge't oiz‘Z | £06SZ | + (sxeak ¥) saSez2ay SN Te aS ean TAS ks See : for bf9 bro | QIV't LES‘z LLV'Y 6zS‘S 1¥g‘gz — : ; . : * sye}0 ], C11 OgI TOS ves cil CL1‘I cool QLS‘L C96'62 g6g1 QgzI QSI bre gbr gSo ovi‘t SgC'I g6c'L LieLL Z6g1 gol vLi goz coy 69S 6z0'I Sge‘r EgL'g gLtL g6gI QzI bri ols vos g6S Se1'T LEVI cgi‘ gboitZ S6g1 gE9 S zZ Sgee | 3s 3 BO 1) fee gee 68 F a ch spapege eu. ce 25 2 8. axe & as ie a. Bo 3 oe a ae eG 3 da ree sa = eae) o am ry Bia ee n tote 3 ° =. pS = ‘9-L-9-SO91 ut sasvasip qopwf ssout ay fo uanas imosf syjwagE puw (sasnv2 Yq) syswagl JoJo] ‘szuapisay Mw aSvsaay SULLOYS—]T AIIVI, ‘SHIVM GNV GNVIONYA—'SWNIASY TIV BY ERIC’ FRANCE, M:B, 1900. | PREC h ret a seas teem e aera — SESE SUnnA HHL ace een ek RS ee = eee Petra |. SS ee AT SRT RA CR a 2A eT aN RE, He a as) ——} Sp} tt tt TEE AND WALES. ENGLAND MSs;-— ALL ASYLU al diseases from 1895 to 1898 total mortality in seven of the most fat « Showing inclusive 28,841 303,032 ing same period Total deaths from all causes dur idents during same period Average daily res ArH IMESRUABBUSESAISESEARAEL SONAL AQENE SHUAE 1000" SVARE ANNREANAAEANAMESTIz9 ay SR SS a a we ee ee es aaamannadaneuniuenanendaaart ant OO a OR [Jan., ISOLATING THE | PHTHISICAL INSANE, ti 7 ise PA oi ete ie ge Ais TP pe pd a fel leer rrp SSBSBEBRGRLARAAEENREEREEE =r} a CHART IA. —— Seas = Se forirrr ie ini ENGLAND AND WALES. Att ASYLUMS.— iseases,. £ the most fatal d in seven o ty e annual mortali 1V g comparat Showin 1895 and 1808. 1895 =shaded. 1898 = white. 1900. | ALL ASYLUMS.—ENGLAND AND WALES. Total Mortality (all causes) to Average Daily Residents. Mortality of Tubercle and Colitis to Average Daily Residents. per 1000 va Ratio Wing TABLE [A.— Sho to Total Mortality (all causes), ” ”) ” L00 of ’” ” BY ERIC FRANCE, M.B. *syjeap 1230} 03 s131109 Ss ants Se re | é uloly Syyeop = = oa | jie jO a8ejUsII0g | on ETTORE TOSS GPS Ln *s]UOpIsoI ISBIIAL 0} SIIOD NS NS ‘© a Ke) wolf SU}EIP Fo ya Ls es oa ooor sad o1vey *Arojuashq¢ ‘s1}19}0q bs pla dis a a ° ‘SI}1109 ” a Piped share nek wooly syyeoqd | “syyeop fe) ™~ ~ > “a Te}0} OF 9pOIIVqGN TL, & 2. ‘© a bf Wolj sy}eop ool nly i we ve jo o3e UDIINg *s]UapIsol ade s <a ae i a =I9AG 0} BPOIOGU, vA = a2 oy Sa WIOIZ Sy}eep JO a rm 4 7 = coor Jed ol} ey ire) O7*) ie) ioe) O* *opotaqn Ty, ft a “iy i e Woy syyeIq Beg = = = = *sjuaptIsol ISEIIAS OF 5 > os op 2 Suyeop [e10} jo oO }7 oO’ fon) Oo ooo! iad o1ey = Smee FSi oheeiols He *sasneo [[e ‘syyeap st ee a Y ve ou i \© NS tS GS toners dae Me TESA Mi “sjuaptser S “< q 3) 8 Ajrep ae8eivay es + NS on Ww i ~ ~ Ss NS yn HH So o > + ; ve) © ~ or) a a a OV a DD s co) ioe) (o.@) (oe) oO = ~ =~ ae es cal re) a o o0 A MH o > < 8 ISOLATING THE PHTHISICAL INSANE, [Jan., LONDON COUNTY ASYLUM. TABLE. II].—Showing Average Daily Residents, Total Deaths (all causes), and Deaths from six of the most fatal diseases in 1895-0-7-8. los NG s o | 3 | 3 be | eo eee Year. Asylums, a. 8 =48 pe 5 Ba |§ 5 : 3 gee | paw | SSE) S45 3 | Ss lee oe] amp gue ee “Gon | Boo Ones a! =o |kaoe O Ona (\Hanwell. 1,964; 164 55 ao 7 8 4 I | |Colney Hatch. 2,219} 198 AI) S23 16 6 8 fe) 18954 |Banstead. ‘| 2,027} 169 35 10s II II 9 O | beCane Hilly ths 2090) Tart 44-25 II I 2 5 { i|Claybury. | 2,342| 350] 128) 29 27 24 5 15 | Totals. .[10,591/1,052 | 301 | 130 72 50 33 21 (|Hanwell. 1,988} 162 41 | 19 3 10 6 7 | | |Colney Hatch. 2,412| 216 41 | 16 7 rm 3 Oo ea) Banstead. .| 2,303) 182 A Ned 4 8 2 fe) Cane Hill. .| 2,112) 158 44.410 16 5 3 2 (jGClaybury. 4 .| 2.40417 258" 92: ). 30 29 72 10 14 Totals... ./:11,300) 1,016.39 205) 07 59 56 24 23 (|Hanwell. 2,052| 147 44| 17 7 3. 7 3 | |Colney Hatch. 2,580| 240 36 | 34 18 II 9 5 18974 |Banstead. .| 2,436) 224 47 | 36 32 14 4 O \iCane Hill ¢ | 2,202) 176 46 | 22 10 4 5 3 \|Claybury. .| 2,494| 249 So |, tO 31 22 7 3 Totals... 31) 11,7042 ,040 auess | 1127 98 44 32 14 (|Hanwell. 2,415) 246 59 | 25 14 II 9 6 | |\Colney Hatch. 2,5554| 207 36 | 26 II 6 5 I 18984 |Banstead. .| 2,436] 199 351 36 aT 24 6 oO | iCane-Hilbl 4) 2argl) 1560 40 1caR 4 7 3 3 LiClaybury. .| 2,488) 267 St 25 23 25 6 18 | Totals. .|12,106)1,078 | 227'| 128 73 72 29 28} Total, 4 years | 4,182 | 1,046 | 482 | 302 | 222 118 86 | ’ : fs. Showing total mortality in five of the most fatal diseases from 1895 to 1898 inclusive. 4,182 11,442 ° Total deaths from all causes during same period Average daily residents during same period. ISOLATING THE PHTHISICAL INSANE, [Jan., IO =a toe safe £ ato +- oa aw Rk ee alnickg =i CHART IIA. ions a as ee one Lonpon County ASYLUMS. atone aS ek pt -f--- f- 28 Soa aul ies Sa  black and white. Showing comparative annual mortality 1898 = white. 1897 =black. 1896 = 1895 =shaded. 1900. | LONDON COUNTY ASYLUM. Total Mortality (all causes) to Average Datly Residents. Mortality of Tubercle and Colitis to Average Daily Residents. per rooo ma 20 Rat wing TABLE [[4.—Sz4o to Total Mortality (all causes). ” ” LOO of ) ” ” BY, ERIC FRANCE, M.B. *syjeop [T@}0} OF STZITOTD) wo1j Sy}eap JO ode}UI0I0g *sJUOPISoI ISIIAL 0} SI}I[OD WO1f Sy}yeIp jo ooor Jod o1}ey *Arajuas hq *st}liajuq *sI}I]OD uWlol} sy}eIqd *syjeop [@}0} 0} 9pOIoqun TL wolf sy}yeap jo o8ejus010g *SJUOPISol o3e -19A O} 9JIIIQN TL, WO1f sy}eep jo Ooo! Jad a}eyY 1°99 21 2°20 2°03 23 1°35 I 2°59 2°05 2°3 14 28 1°8 21 12°35 I2°2 9°55 85 12°25 10°8 11°87 10°60 1152 10°58 *g[0JaqNy, woIy SY} ea] 130 97 127 128 120 *sJUdpIsal ASEIIAL 01 syyeap [e}0} Jo ooor iod o1; ey *sosneo [je ‘syyeop [e10L 99°3 1,052 89'0 1,016 *s]UOpISor Ajrep o3e19ay Year. 10,5901 1895 II,309 1896 1,030 880 11,764 1897 89'0 913 1,078 1,045 12,106 11,442 1898 Average for the 4 years II ge ISOLATING THE PHTHISICAL INSANE, [Jan., If it may justly be supposed that a similar proportion exists in the other asylums of England and Wales, it is apparent that the figures representing the incidence of tubercle in these insti- tutions must be doubled before they can be regarded as actually representing the case. This fact alone would more than justify a vigorous attempt to reduce this heavy mortality, but there are other reasons which should stimulate us to take some decided action in this matter. Public interest has recently been aroused in a gratifying degree to the importance of action being taken against the tubercle bacillus. I need only refer to the establishment of the National Association for the Preven- tion of Tuberculosis, and to the excellent work it is doing ; and to the untiring efforts of the Medical Officer of Health for Manchester—Dr. James Niven,(”) and the Medical Officer of Health for Sheffield—Dr. John Robertson,(*) both of whom have strongly urged the compulsory notification of phthisis. Dr. _Niven’s last annual report, and the special report on tubercu- losis published this year by Dr. Robertson, both contain much valuable information, and will repay careful study. In each report the obvious fact is strongly emphasised that notification is essential to any coherent scientific attack upon this disease as it exists among the general population. But we, as Medical Officers of asylums, are in this more fortunate position. We have no need to wait for such a thing before we can hope to cope successfully with tuberculosis. ; The time has now come when some definite effort must be made to reduce this excessive mortality from tuberculosis among the insane. I am glad to be able to state that the Asylums Committee of the London County Council has this matter under consideration. The question remains, what is to be done? ‘Iwo years ago I urged upon this Association that if the prevention of the spread of phthisis could be summed up in one word, that word was /solation.(*) This opinion has the powerful support of Sir James Crichton-Browne, who, in a speech at the Poor Law Conference, said, “Our greatly increased, and now exact knowledge of the nature of tubercular disease, and of its mode of propagation, makes it, in my opinion, obligatory upon those having control of public institutions into which tuberculous patients are received to arrange for their complete separation from the other inmates.” 1900. | BY ERIC FRANCE, M.B. 13 No thoughtful person will now deny the necessity for isolating the phthisical; and if the importance of isolation be eranted, the crucial point of diagnosis at once presents itself. An early diagnosis affords the best opportunity of placing the patient in such environment and under such treatment as is most suitable for his recovery, and when isolated in the early stages of the disease he has not begun to disseminate the bacillus to the detriment of others. Whatever means be adopted for definitely diagnosing active tubercle in suspected patients, whether it be by a careful study of their body-weight and temperature, or by a microscopical demonstration of the tubercle bacillus in the sputum, or by the inoculation method advocated by Sheridan Delépine,(°) it cannot be too strongly urged that an early and accurate diagnosis must be made if isolation is to be of real service either to the patient or to the community. We are well aware how little ordinary diagnostic rules and _ methods apply to insane persons, and how frequent and great is the difficulty in diagnosing phthisis in them. For these reasons, as well as the importance of an early diagnosis, for about eighteen months at the Northumberland County Asylum (where the death-rate from phthisis was very high——about 40 per cent. of the total deaths) I relied almost entirely on the diagnostic power of single minute subcutaneous injections of Koch’s original tuberculin. This method was adopted because, in the majority of insane patients, physical signs in the chest were found to be untrustworthy, misleading, and often paradoxical in the early stages; and because the valuable method of microscopical demonstration of the bacilli in the sputa was seldom pos- sible. At that asylum I injected seventy-five cases with tuberculin, and am satisfied, not only with the accuracy of its diagnostic power, but also with its entire harmlessness, both in the tuber- cular and in the non-tubercular. Every patient was carefully weighed at the beginning of each month, and every one who had lost more than 5 lbs. in the month, or in whom gradual loss of weight over a longer period had occurred, was examined and the cause of the foss of weight minutely inquired into. If this could not be readily accounted for by some obvious mental or physical cause, such as refusal of food, the patient’s © name was placed upon the “suspected list.” The same thing 14 ISOLATING THE PHTHISICAL INSANE, [Jan., was done in the case of any patient giving at any other time the faintest cause for suspicion of the presence of tubercle. All those on the “suspected” list were then injected with tuberculin in the following way :—The patient was put to bed and the temperature was taken. The next day, with rigid antiseptic precautions, I c.c. of a ‘OO1 solution (made by diluting I c.c. of Koch’s original tuberculin, issued under a guarantee of Dr. Libbertz, who acts under the direct supervision of Prof. Koch, with a *5 per cent. solution of carbolic acid) was injected subcutaneously, and the temperature taken every three hours. If the temperature rose 2° or more within the next twelve hours tubercle was diagnosed. With regard to the seventy-five cases injected, twenty were non-suspects, or control experiments ; in none of these was a reaction obtained. The remaining fifty-five were suspected of having tubercle, and gave the following results : 55 “Suspected” Cases injected. | 45 reacted. 10 did not react. | 34 Ane 11 still live, He We 6 had merely local tubercular | lesions, viz. cervical glands, strumous dactyl- itis, etc.; 1 discharged mentally recovered; 1 going downhill with physical signs; 3 results | wanting. a 29 vane made. Active tubercle found in every case. 5 no P.M.’s made. 4 certi- 5 died and P.M.’smade. 5§ ae alive fied as “phthisis pul- No trace of tubercle and healthy monalis.” 1 certified as found in any. (July, 1899). “general tuberculosis.” Grave fears have been expressed that even single minute injections of tuberculin might possibly re-awaken dormant tubercle, or lead to its dissemination through the tissues, I have been quite unable to discover any grounds for such fears. Koch states that out of more than one thousand persons in whom tuberculin was used diagnostically there was not the least indication of dissemination of the disease.(°) “These facts,’ says he, “should suffice to make us, once for all, abandon the absurd idea of the possible stimulation of the tubercle bacilli, and should encourage us to apply tuberculin to 1900. | BY ERIC FRANCE, M.B. 15 the diagnosis of tuberculosis in the human subject.” Since my first paper was published on this subject tuberculin has been tried, and its value as a diagnostic agent extolled by Dr. G. A. Heron (“) and Dr. McCall Anderson (*) in this country ; by Dr. James T. Whittaker,(?) Dr. Franklin T. White,’°) and Dr. Irving H. Neff("”) in America; by Drs. C. F. Martin and G. D. Robins, of the Royal Victoria Hospital, Montreal ; (**) by Prof. Brieger, in a speech before the recent International Tuberculosis Congress at Berlin,(’*) and by Prof. Clifford Allbutt, who, in his address on the prevention and remedial treatment of tuberculosis at the annual meeting of the British Medical Association last August,(*) referring to the diagnosis of early tuberculosis and its attendant difficulties, says, “ Tuber- culin seems to be almost a certain test of the presence of tuberculosis in its early stages. . . . In England I think most of us have been reluctant to arouse the reaction, but Dr. Turban follows other German observers and Prof. Osler in assuring us that he has never seen any harm ensue from it, although he always keeps the patient in bed until the reaction has wholly subsided. The old tuberculin is preferred for this purpose. Of all our means of detecting early tuberculosis this may prove the most valuable.” It is to be clearly understood, however, that I advocate this method of diagnosis only in those cases where the presence of active tubercle cannot be definitely diagnosed by other means, and that a monthly record of the true body-weight of asylum patients is of the greatest importance, as I stated in detail in my original paper in 1897.(*) Referring finally to the question as to how dsolation may best be provided for the phthisical insane, it would be beyond the scope of this paper to do more than offer one or two sugges- tions, omitting structural, administrative, and financial details, which must, of course, be left in the hands of those who adopt this means of prophylaxis. I recently contributed a paper to the Archives of Neurology, from the Pathological Laboratory of the London County Asylums,(’*) referring particularly to these asylums, and may be permitted to repeat it in part. “Two schemes at once suggested themselves: one is the erection of a central isolation hospital for phthisical patients, common to all London county asylums; the other is the building of cheap temporary bungalows at each of these 16 ISOLATING THE PHTHISICAL INSANE, [Jan., asylums. Each scheme has its advantages. The selection of a site, specially adapted by reason of its elevation and its soil, is certainly in favour of a central hospital ; while the difficulty and expense of the transference of patients appears to be the chief argument against it. It is now held by eminent authori- ties that the successful treatment of phthisical patients depends more upon how they are treated than where, more upon perfect hygienic surroundings than upon climate and _ soil.(*®) The idea, therefore, of a bungalow built upon the estate of each asylum appears to me to be a very attractive one.” “In conclusion I should like to suggest that a temporary bungalow should be erected as an experiment on the Claybury estate. I am given to understand that such a building could be obtained, which would meet all requirements and accommo- date twenty-five patients of each sex, that is 2 per cent. of those in the main building, for a comparatively small sum.” (1) Journ. Ment. Sci., October, 1899.— (#) City of Manchester M.O.H.’s Annual Report for 1898.—(*) City of Sheffield, Special Report by M.O.H. on the Prevalence of Tuberculosis, 1899.—(‘4) Journ. Ment. Sci., October, 1897.— (°) Brit. Med. Journ., September 23rd, 1893.—(®) Deut. med. Woch., April, 1897.— (‘) Brit. Med. Journ., 1898, vol. ii, p. 77.—(*) Ibid., 1898, vol. ii, p. 495.— (°) Trans. Assoc. American Physicians, 1897.—(}°) Boston Med. and Surg. Journ., 1897.—(1!) American Journ. Insanity, January, 1899.—(3#) Brit. Med. Journ., 1898, vol. i, p. 357.—(38) Ibid., 1899, vol. i, p. 1348.—(#*) Ibid., 1899, vol. ii, p. 1153.—(%) “The Prevention of Phthisis in the Insane,” Archives of Neurology, from the Pathological Laboratory of the London County Asylums, 1899.—(?*) Vide paper by Dr. A. Ransome on the “ Open-air Treatment of Consumption,” Brit. Med. Journ., 1898, vol. ii, p. 69. DISCUSSION. Sir WILLIAM BROADBENT.—I have come here with great pleasure to endorse what I understood were the conclusions arrived at by many officers in asylums, namely, that it is the duty of those who are concerned in the management of asylums to make provision for the isolation of phthisical patients. I have heard with very great interest the paper, and have seen confirmed, as had generally been understood, that the mortality from tubercular disease in asylums is, one might almost say, ‘enormous. Anyhow, it is so large as to demand very special attention ; and unless we are to look upon our insane patients as people whom it is desirable to get rid of, we must do our best to keep alive those who are committed to our charge, although asylum subjects. They are a melancholy spectacle, 1900.] DISCUSSION. 17 yet they are human beings, and it is our duty to do everything that can be done for their welfare, and even for the prolonga- tion of lives which are not altogether the happiest. One of the points of interest which one would have liked to hear illustrated more completely was the comparison between the mortality from phthisis and tubercular disease generally, inside asylums and outside. It is understood of course that that comparison could only be accepted up to a certain point ; that there are many considerations applying to inmates of asylums which do not apply to those who are living an active life outside. It would, however, have been a matter of great interest to know exactly what the proportion was. Taking the absolute prevalence of consumption, one questions what it is due to. Of course I know less of the actual life in an asylum than perhaps anyone here, but one can see that there must be conditions which are extremely favourable to the dissemination of tubercle. For a considerable portion of the twenty-four hours the inmates of asylums are under cover. ‘The necessity for warmth—the warmth which is necessary for these enfeebled organisations—must frequently interfere with efficient ventila- tion. You cannot teach an insane patient the precautions which are necessary to prevent contamination of surrounding objects by the sputum, and, as Prof. Clifford Allbutt pointed out in the address already alluded to, it is not simply the mass of expecto- ration which can be collected which has to be dealt with; it is the spray which is disseminated in the act of coughing which is often richest in these tubercular germs. Whether these conditions alone, the necessary confinement indoors, the neces- sary association in large dormitories, the difficulties of prevent- ing the expectoration from contaminating surrounding objects, explain the great prevalence of tuberculosis in asylums, or how far they are accountable for it, I am not prepared to say. There is of course the other side, namely, the fact that insane people are weakly organisations, and probably more predisposed from the fact of their disease as well as from the necessary limitations to their outdoor exercise. We have, therefore, in asylums exceptional conditions which favour the dissemination of tuberculosis, and this would imply that special precautions should be taken to prevent such dissemination. For this end I can imagine nothing better than the plan which has been proposed this evening,—that all patients in XLVI. 2 18 ISOLATING THE PHTHISICAL INSANE, (jan; - whom there is a reasonable suspicion of tuberculosis should be tested by tuberculin. From all that I have heard regarding this test, it is absolutely safe. There is no fear of any harm being done to the patient, and reaction of it is undoubtedly the most trustworthy evidence we can possibly have of the existence of tubercle. Then it seems also that every large asylum, surrounded as it is by extensive grounds, has facilities for isolation and for treatment, and it has been a satisfaction to me to hear so excellent a scheme propounded, and so far as my judgment goes it is entirely deserving of support. Sir JAMES CRICHTON-BROWNE.—Your discussion this after- noon, founded upon the excellent paper of Dr. France, to which I am sure we have all listened with the utmost attention, has reference to the necessity for isolating phthisical patients amongst the insane in lunatic asylums ; and I take it therefore that that necessity is already recognised, and that it is the method by which isolation may be economically and effectively carried out that is henceforth most likely to engage your attention. Now it seems to me that since the publication of the statistics, marshalled and set forth in Dr. Crookshank’s very able and lucid paper on pulmonary phthisis, to which the medal of the Medico-Psychological Association was awarded, reinforced and confirmed as they are by the tables and the figures submitted to us to-day, it becomes an imperative necessity to provide for the isolation of phthisical cases’ in asylums. Dr. Crookshank has shown that the official mortality from phthisis in our asylums—and I can discover no flaw or fallacy in his figures or his conclusions (and it is to be remembered that the official mortality falls considerably short of the real mortality),—-he has shown that it is ten times that of the phthisis mortality in the general population, and is four and a half times that of the phthisis mortality in men from thirty- five to forty-five years of age,—that is to say, in the particular age group in which the mortality from phthisis is highest in the general population. Dr. Crookshank has also shown that whilst the mortality from phthisis in England and Wales has fallen during the last thirty years by 30 per cent., there has been no reduction in the mortality from phthisis in asylums, at least during the last twenty years. Making all possible allowance for errors in these statistics, sift and rearrange them as you will, it is incontestably established, I 1900.] DISCUSSION. 19 think, that phthisis pulmonalis is prevalent and is the cause of death in our public asylums in this country to an unnecessary extent ; that it is to a very considerable degree generated and propagated in them. Well, gentlemen, I have long held that opinion. Dr. Crookshank says that in 1892 I recommended the erection of detached blocks to be used as hospitals for consump- tion in connection with our public asylums, but long before that I had advocated isolation. I hope I shall not be regarded as egotistical if [ quote a sentence or two from a paper of mine that appeared in Lrazm in 1883, that is exactly one year after Koch had discovered the special bacillus in tubercular disease, and had shown that it could be isolated and culti- vated, and that the disease could be reproduced in its inocula- tion. I said that in 100 general paralytic patients dying in the West Riding Asylum, consecutive cases, in all of which general paralysis was the certified cause of death, tubercular disease of the lungs was found in 25 cases ; in 17 out of 80 men, and in 8 out of 20 women. In 6 of these cases only the remnants of past phthisical disease were noted, crustaceous nodules, cicatrices, etc.; but there was no room for doubt that in 19 cases the disease had arisen during the course of the general paralysis, and had been cut short by the natural termination of that malady, which it had perhaps in some degree hastened. In none of these had the disorganisation of the lungs spread to the extent which we are accustomed to find in patients who have died of phthisis. I go on to show the reasons that led me to believe that the phthisis in these cases was contracted in the asylum, and the special reasons why general paralytics suffer in this way, and also to explain that the mortality was larger in female lunatics in asylums than in males. I conclude with these words: “ Until Koch’s theory is disproved it would be prudent to act on the assumption that it is true, and to prevent the close association of persons actually suffering from phthisis with those who, from inherited tendency or deterioration of health, are especially liable to contract the disease. A large number of lunatic asylums have now detached hospitals for contagious diseases, which fortunately stand empty for a great part of the year, and it might be well to isolate in those buildings all cases of phthisis. The experiment could do no possible harm, and there is every prospect that it would be attended with benefit 20 ISOLATING THE PHTHISICAL INSANE, [Jan., to the victims of phthisis, and with safety to those who are in danger of its attacks.” From this extract you will gather that I then proposed the isolation of phthisical cases in asylums, but at that time my proposals fell upon deaf ears, and if I recollect rightly they were ridiculed in certain quarters. Nowadays, as Dr. France has told us, we are all tolerably well agreed as to the merits of isolation, we are all agreed that a stringent obligation rests now upon asylum medical authori- ties to provide means for separating phthisical from the non- phthisical patients. But though we are theoretically agreed upon that point, much remains to be done before practical effect can be given to our agreement. Quite recently I saw a patient of mine in the last stage of phthisis in a large public asylum in this country, in a single room, the walls of which, the floor of which, besides the bed and the bedding, bore visible traces of dry phthisical expectoration. The single room occupied by that patient opened into a large. ward in which patients were constantly passing to and fro, and they had access to the room if they desired to enter it, and it is not improbable they had whiffs of the tubercle bacilli as they passed the door. That sort of thing should not be, but it is still to a large extent unavoidable, for even where our asylum medical officers are deeply convinced, as I believe most now are, of the necessity for isolation, and eager to carry it out, there is still in many cases no possibility of doing so because of deficiency of accommodation for isolating and separating phthisical patients. But, gentlemen, I venture to predict that that sort of thing wili not go on very long, for whenever it becomes generally 1900.| DISCUSSION ai and popularly known that a certain proportion of lunatics in our asylums, deprived of their liberty, for the protection of the public or for treatment of affections of the brain and nervous system, while detained there are liable to be infected by a disastrous and often fatal, sometimes preventable disease, then I say that there will be an urgent public demand for isolation, and for preventive measures, above all for that primary pre- ventive measure that is of paramount importance—the separation of the diseased from the whole. I need scarcely remind you that in no class of phthisical cases is isolation more absolutely essential than in those in which phthisis is associated with insanity, for in those patients it is impossible to secure the observance of any minor pre- cautions. It would be impossible to compel them to use special spittoons or handkerchiefs, or observe strict cleanliness, and there is nothing for it but their prompt removal from associa- tion with companions to whom they may become a source of danger of lung contamination. Expense must not standin the way, and sure I am that whenever the Medico-Psychological Association has definitely made up its mind as to the system of isolation that ought to be pursued, then County Councils will at once generously and freely provide the requisite funds. The isolation of the phthisical insane is not by any means an easy or simple problem. There are great difficulties and obstacles in connection with it, but I feel sure that these will speedily disappear when once our asylum medical officers have taken the matter seriously in hand. In the meantime it does seem to me that those existing detached hospitals for in- fectious diseases which are attached to so many asylums ought to be as far as possible employed for isolation, so that phthisical patients may be promptly removed from the wards, where they are apt to be distributors of disease, and that where no such detached buildings are available special wards should be set apart for the phthisical patients. Very shortly, I have no doubt, sanatoria and special buildings will spring up in connection with our county asylums, provided singly by counties in the case of the large and populous counties, and perhaps in the case of small counties by several acting in con- junction. We shall have sanatoria in which isolation may be thoroughly secured, and in which the modern sanatorium or open-air treatment may be adequately carried out, combined 22 ISOLATING THE PHTHISICAL INSANE, [Jan., with that medical treatment of phthisis of which, I trust, we shall never lose sight. | During the course of last summer I ventured to urge upon my friend Dr. Hayes Newington, who is taking so - active and so useful a part in connection with the building of the East Sussex Asylum, that he should there provide a sana- torium for phthisical patients on the plan of Dr. Burton Fanning’s sanatorium at Mundesley—-a simple wooden building with verandahs, shelters, and all necessary appliances for open-air treatment. In connection with some small asylums a chain of villas might be a suitable means of providing for such patients ; but whatever style of building be adopted all apartments ought to have Parian cement walls and ceilings, so that they may be cleansed from time to time by hot formalin spray, discharged under pressure, the most powerful disinfectant known for use on the large scale. Where wooden buildings are adopted I would suggest that it should be stipulated that they are to be burnt down always at the end of ten years. But isolation is not everything. There are many other pre- ventive measures that must receive close and constant attention. 