Dr. Weatherly, in introducing a discussion upon the above subject, said its gravity would perhaps appear to them greater when they were told that in one town of England, such as Liverpool during last year, every time the clock hand went round and indicated that another four hours of time had gone by, a life was passing away in that town from consumption; when they further were told that in that one town of Liverpool more young people died of consumption in 1899 than had up to the present been killed in South Africa during the present war. The great thing, however, for them to think of to-day was, “Is there any need to do anything with regard to phthisis in our asylums?” Once they accepted that there was; then came the question, “What was best to be done?” The premiss upon which he should like to start the discussion that day, was a sentence uttered in London a short time since in a most able speech by Sir James Crichton Browne, in a discussion which took place following the paper by Dr. France. He said, “Phthisis is prevalent, and is the cause of death in our public asylums in this country to an unnecessary extent,” and he went on to say that “it was to a very considerable degree generated and propagated in them.” It was known that young healthy people with possibly a predisposition to-phthisis entered asylums, became phthisical patients, and propagated disease far and wide. The first question asked would naturally be, “Why is this?” This brought them, to his mind, to the most difficult position in which they found themselves. Personally he did not think there could be any doubt that what Dr. Cruikshank in his prize essay said was absolutely true, viz. that it was due first and foremost to overcrowding; secondly, to lack of sufficient exercise and pure air; and thirdly, to a certain quality of dietary. These were the three reasons he brought forward, and which were very much emphasised by Sir James Crichton Browne. With regard to overcrowding, he thought the modern tendency of piling building on to building at their big asylums was one that ought to be very greatly deprecated. With regard to the lack of exercise and pure air, one had no doubt always felt there were difficulties in the way. It seemed to him that every patient should be made to live during the greater part of the year a great deal more out of doors than was the case at present. This was more especially necessary in the case of women, among whom they found phthisis much more prevalent than among men. Those who were not strong enough to take exercise might have shelters made for them in which they could lie or sit. Another question was whether or not a definite rule might be made in all asylums that during certain periods of the day every single inmate of the ward or corridor should be taken out of those corridors or wards, and a free draught of fresh air with open windows be allowed to circulate through every part of it. He believed there was nothing so good as a direct ventilation of pure air through the windows of their wards; but he was persuaded that the greatest thing for them to discover in England was how to get efficient direct ventilation without draught. He saw no reason why the windows of all asylums should not be made with the bottom part to open outwards or inwards, as a French window, whilst the upper part was a flap window, opening outwards or inwards as desired. Dr. Weatherly went on to describe this window more in detail. With a window like that they might always keep the upper part open, and obtain any amount of fresh air without any possible draught In dealing with the question of the quality of the dietary, he was aware that he was touching on a very tender point. It seemed to him, however, that it was a very sad thing that there was an inclination on the part of management committees to pat on the back a superintendent who was able to show that he could keep his expenses per head of maintenance at a very low rate. (Hear, hear.) He felt very seriously that if committees of management spent a little more money on a more generous dietary—he would say nothing about the quantity, that was ample, but in obtaining a more varied, more nutritious and fatty dietary—it would be a very great benefit. If they spent a little more on the food of the patients, and a little less on palatial buildings, they would be doing far more good in checking the spread of this terrible disease. (Hear, hear.) With regard to what could be done, first of all, to prevent the starting of phthisis, he would suggest that the number in the building be lessened. Then there was the tremendously difficult question of the expectoration. They did not find it impossible to inculcate cleanly habits in the case of dirty patients who entered their asylums, and he could not help thinking that if they adopted some such rules as were in force in different sanatoria for the treatment of the disease, beneficial results would follow. He advised the placing of spittoons fastened by locked rings in all corridors and wards, utensils by all bedsides; the posting of rigid rules, and the provision of some form of handkerchief for expectorating purposes which could be thrown away and burnt at once. Difficulties would arise, he knew, but he believed that by these means much good would be done. In the sanatoria in Germany rules were posted on the walls in all parts of the building to the effect that any one found spitting on the floor of the corridors or rooms, or outside on the walks, would be discharged, and, although they might be paying four or five guineas a week, they were sent away if they persistently disobeyed this rule. Then the nurses had also definite rules given them. They had always disinfectants handy, and a sort of mop with rag or soft paper at the end, which could be burnt after use, and with which if they saw any expectoration on the floor they could, after applying disinfectants, immediately mop it up. Another great difficulty they had to contend with was the diagnosis of phthisis in their patients. They found that in ordinary cases the most skilled physicians had a difficulty in diagnosing this terrible disease in its early stages, how much more difficult was it then in asylums for the insane! Dr. France and Dr. Cruikshank both suggested that medical officers of asylums should keep a very strict look-out upon the weight of their patients, and also spoke about monthly weighing. Personally he thought they ought to go a step further, and weigh their patients once a week, particularly in cases where it might be found they were not taking their food properly. The question of temperature was also a most important one. The old idea used to be that one of the distinguishing symptoms of phthisis was the evening temperature of the patient rising higher than the morning. He could say from his own experience that such an idea was quite fallacious. A patient with a temperature normal morning and evening might possibly have a temperature of 102° at 12 o'clock in the day. There was absolutely no rule, except that in some period of the twenty-four hours there was fever. If they wished to diagnose phthisis, he advised that the temperature be taken in the morning, again at 12 o'clock, at 4 or 6, and also the last thing at night; and then if they found at any of those periods the temperature rising above normal, they should be very suspicious. He would not dwell upon the tuberculin test because that had already been threshed out pretty exhaustively. An important question which they had to consider, however, was what they could best do when they had the least suspicion of having a phthisical patient in their midst. He believed this to be a matter which they must grapple with definitely and decidedly. They had to deal, first and foremost, with a phthisical patient, and secondly with an insane phthisical patient; and it became absolutely necessary that whatever sanatoria treatment they adopted must be in the shape of another asylum for those patients. He would say generally that no definite rule ought to be made. The site of one asylum might have ground of easy access, in every way applicable to sanatoria, while in the case of another it might be that it would be impossible or entirely wrong to build a sanatorium near. To ensure success they required to be built on sandy or gravelly soil, which dried quickly, with woods where the patients could have sheltered walks, and with a south aspect, in order that the dwelling and sleeping rooms might be protected absolutely from the north and east winds. There was nothing which handicapped the treatment of phthisical patients more than bronchitis, and there was nothing more calculated to give bronchial catarrh in phthisical cases than when the patient was subjected to northern or easterly winds. Then came the question whether it would be feasible in some cases for two county asylums to join hands in the matter and have a decent sanatorium which should be within easy distance of either, with its own medical officer. He was strongly of opinion that to build small detached cottages for such a purpose would be a waste of money. By removing phthisical patients from their asylums, and treating them in other buildings, they would, he suggested, be going a long way towards solving the difficulty which now existed in many cases of lack of accommodation for ordinary cases. His own feeling was that they could build a suitable sanatorium in England at £200 a bed, and give each patient a separate room to sleep in.
