STATISTICAL RETURNS OF THE LUNATIC ASYLUMS.                            37

treated with permanganates and hypertonic saline intravenous infusion, but the
bacteriological examination of the stools demonstrated that the disease was not
cholera.

Obviously the means by which we may hope eventually to eradicate dysentery
from asylums are those by which enteric has been practically eradicated from the
army, viz.:—

I.   The isolation of all carriers, until they cease to be such (which in chronic
cases usually means isolation for the remainder of their lives).

II.  The immunisation of individuals who are exposed to infection, by
inoculation.

III.   The adoption of the most reliable and up-to-date sanitary methods for
the preparation of food, for the protection from contamination of food and drink-
ing water, for the treatment or destruction of excreta, for sewage removal, and for
housing and clothing the population we deal with all this with two objects:

(a) to raise the standard of general health as high as possible, and (b) to
minimise the chance of the ingestion of infected or contaminated matter by the
individual.

These are the only ways in which general sanitation affect the matter.

But in carrying out these measures, in the case of lunatic asylum populations,
enormous difficulties arise, apart from the questions of expense and accommodation.

These are—(a) as regards the disease itself :—

I.  Bacillary dysentery varies in degree from a condition scarcely noticeable to
a condition as rapidly fatal as Asiatic cholera. Very mild cases, if unnoticed, may
go on to ulceration in the sigmoid region, and become chronic carriers, yet show no
symptoms beyond the occasional passage of a little mucus or a little blood with a
formed stool. Such cases are, amongst lunatics who do not complain of disease,
obviously likely to occur. Even, if noticed, such cases are liable to be looked
upon as cases of slight internal hæmorrhoids. Bacilli of the " Flexner " type were
isolated from the stools of such a case in the Madras asylum.

II.  We have no means of knowing when an individual ceases to be a carrier.
As pointed out, it is practically hopeless attempting to isolate the bacilli from fæcal
stools, and the agglutination reactions do not help us. The only method which
suggests itself to the writer is inoculation with a large dose of Shiga-Flexner
emulsion, and observation of the reaction, on the lines of the "Mallein" and
"tuberculin" tests.

The disease is very common amongst the general population. The post-
mortem records of Madras institutions bear out this statement. It is the exception
to find a healthy colon post-mortem amongst hospital patients. Warders, cooks and
sweepers suffer from disease, conceal it, and treat it with indigenous medicines.

III.  A large portion of asylum patients are filthy in their habits, are copra-
phagic, or are earth, mud, and rubbish eaters. Their instincts are perverted or
destroyed. Many are technically " wet and dirty," and even under most rigid
supervision, cannot be prevented from easing themselves in the yards and grounds.
When suffering they do not complain. The vicious circle is obvious—soil and
room contamination can only be avoided by the provisions of impermeable floors
and washable walls.

IV.  Prophylactic inoculation, so far, has not been successful.

                                       References.

(1)  Manson. Tropical Diseases, 1898.

(2)  Report on Asylum Dysentery. Durham & Mott, 1900.

(3) Journal of Mental Science, October 1913.

(4)  Journal of Mental Science, January 1914.

(5)  British Medical Journal, 1908.

(6)  Journal of Mental Science, January 1914.

(7)  Rogers' " Dysenteries," 1913.