STATISTICAL RETURNS OF THE LUNATIC ASYLUMS.
35
PROPHYSAXIS.
The measures taken have been :—
I. The treatment of all dysentery cases in the isolation sheds.
II. The segregation and observation of convalescents for six months
after recovery (in the case of criminal patients—on account of difficulties of
accommodation, this can be only partially carried out). It is noteworthy that Dr.
Bolton holds that, in asylums, isolation of dysentery cases should be permanent !
III. The incineration of the excreta of all dysentery patients and of
convalescents.
IV. The boiling of drinking-water.
V. Prophylactic inoculation of all patients exposed to infection. Of
these, V is the only one calling for detailed notice.
Prophylactic inoculation was begun in November and December 1913, when
533 patients were inoculated, and the remaining 50 cases kept as controls, a
number which has now swollen to 130 by new admissions (up to July 1914). The
vaccine used was prepared from four Flexner and four Shiga strains, isolated from
stools of previous dysentery cases. It was made up in a bacillary emulsion of the
approximate strength of 100 million dead bacilli in one c.c; and two c.c. were
given hypodermically, twice, to each patient, with an interval of ten — fourteen
days between the inoculations.
Reaction was extremely slight, and occurred chiefly in the case of individuals
who had previously suffered from dysentery—a fact which may be of some import-
ance from the diagnostic point of view, and which will be further investigated.
Even in these cases, the general temperature did not exceed 100 F. In six cases,
localised tissue necrosis occurred, with the formation of small abscesses contain-
ing a "pus" which proved sterile on bacteriological examination. The possi-
bility of a little hot vaesline having been injected accidentally with the vaccine
cannot be excluded in these cases.
The results of this inoculation in 1913, from the point of view of prophy-
laxis, have been unsatisfactory (vide table V), and the agglutination tests after-
wards carried out have given contradictory results, especially as regards the
mannite fermenting or Flexner type of organism. An emulsion containing 2/3
Shiga type and 1/3 Flexner type bacilli was used in inoculating all the asylum
patients in August of this year.
Post-mortem Records.—During the 3½ years under review 242 deaths occurred
in the asylum, and post-mortem examinations were made in 167 of these. In 34 of
these post-mortem or 20.4 per cent. dysenteric lesions of the bowels were found; in
another:25, or 15 per cent., tubercular ulceration was present. But in not one
case was any trace of abscess of the liver found. The writer has searched the
asylum post-mortem records in vain for any record of liver abscess having been
ever found post-mortem. This fact in itself is an extraordinary one, and goes a
long way to prove that the dysentery, which has been endemically present, is
essentially bacillary in type.
General treatment.
All patients who are reported as having passed a dysenteric stool are sent to
the isolation hospital, and put upon castor oil emulsion 3ii to 3i, of which 3ii are
given, followed by 3ii given every three hours for the first 48 hours. The writer
remembers the success of saline treatment in the asylum in which he worked at
home. His Superintendent's instructions to him were "Turn your cases of
dysentery into cases of plain watery diarrhœa, with Glauber's Salts and then, if
necessary, cork them up with a little opium."
This plan worked excellently in Tipperary, but was a failure in Madras. The
Madrasi's constitution could not stand it. The writer employed it, in his own
case, with complete success.
In addition to castor oil by the mouth, rectal lavage with boric acid solution
followed by albargin, grains 4 to the pint, alternating with Pot, Permanganate
10