In following up Dr. Manning's paper in the July number of this journal with these fugitive notes of a series of very pleasant and instructive visits, I would premise that the changes of three years have taken place since it was my fortune to spend a season in Australia—that most hospitable of countries. Victoria has lost Dr. Robertson, and Queensland Dr. Jaap—gaps not readily filled up in a remote and little-known service. Administrative changes in the progressive spirit of the Australian commonwealth have swept away faulty arrangements, but the struggle for improvement remains in able hands and with stout hearts.

The Annual Reports of the Commissioners in Lunacy possess a special interest to those who are engaged in the care and treatment of the insane, taking, as they do, a comprehensive survey of facts which can ordinarily be viewed only from a limited standpoint; and they have a general interest for the public, because these facts bear a distinct and an intimate relation to questions which materially affect the wellbeing and progress of society. At no period has this been more the case than at the close of a year, which has been marked by a concentration of public attention upon the seclusion and treatment of insane persons such as has not occurred since the passing of the Lunacy Acts towards the middle of the century. Moreover, the burden of insanity has been yearly increasing, and its fiscal relationships have assumed an importance which the diminished prosperity of the country has brought into more than ordinary prominence.

Since my last report (in 1898) to this Journal no important changes have taken place in the care and treatment of the lunatics in this country.

The term “dysentery” in mental hospitals may be regarded as applicable to a clinical entity characterized by symptoms of abdominal pain, rise of temperature and passage of blood and mucus. The causative organisms are various, but that occurring most frequently and persistently is the Bacillus dysenteriæ of Flexner. This paper deals exclusively with this type of asylum dysentery.

At various times attempts have been made to establish a specific pathological entity “acute lethal catatonia”. Stauder and Scheid (quoted by Mayer Gross et al., 1954) among the older writers have collected a number of fatal cases and more recently Locher (1941) has suspected qualitative difference in the type of illness of those mental patients who die suddenly in an acute catatonic state. However the general view nowadays seems to be that death is due to exhaustion or intercurrent illness. A fatal outcome is very unusual in current practice perhaps because of improved therapy. The symptoms of acute catatonic schizophrenia are so striking that a determined quest for a biochemical basis for the whole schizophrenic process has been sought in this, its most dramatic manifestation. Success in this direction has often been claimed (e.g. Fischer, 1953; Rieder, 1954; Gjessing, 1953, inter alia) but has also frequently been disputed (Georgi, Rieder and Weber, 1954). The following case is reported because the symptoms seemed to be clearly related to physiological change. It tends also to throw further doubt on the entity of acute lethal catatonia of Locher. Interesting EEG findings and characteristic response to amytal are also noted.

The nineteenth Year-Book (1894) of the New York State Reformatory reflects, even at the first glance, the period of trouble from which the Reformatory has only lately emerged. It is a very plain and unpretentious document, without even a single illustration. Although the charges which have been brought against the Superintendent, Mr. Brockway, do not affect the special characteristics of the institution, i.e., the indeterminate sentence and the system of physical and psychic treatment now familiar to readers of this Journal, they tended to throw discredit upon the Reformatory, and moreover random and ignorant statements of the case appeared from time to time in England, even in influential medical journals. As the matter has cow been fully investigated and finally settled, it may be worth while briefly to set forth the results.

The first clinical histories of this condition were reported in Norway by Stengel (1826). Batten (1903) described changes in the macula in two members of a family who had undergone progressive mental deterioration with loss of visual and motor functions. Vogt (1906) published similar cases and attempted to delimit them as a juvenile form of Tay Sachs disease. It differed from the infantile form in that it occurred in childhood after a period of normal development; the rate of progression was slower; it was not limited to Jewish children and the ophthalmological appearances were those of optic atrophy. The following year Spielmeyer described the pathological changes in juvenile Tay Sachs disease as essentially similar to the infantile form. Further detailed pathological studies were made by Greenfield and Holmes (1925).

Considerable attention has recently been directed by several observers to adolescent insanity and dementia præcox, and an increase in the numbers of these varieties, especially of dementia præcox, has been stated to occur, which means an increase in the more hopeless and demented cases. Dr. Wood, for instance, at the Annual Meeting of the Medico-Psychological Association, remarked on the increase in the number of cases of mental breakdown during the age of puberty and adolescence among persons of the upper and middle classes— the ages of which on admission he placed at from eighteen to twenty-eight years—and he suggested as a cause the greater strain of education and the worries of life during the present time. Again, at a meeting of the Section of Psychological Medicine of the British Medical Association, Dr. Robert Jones mentioned an increase of dementia præcox and a general increase of the less curable forms of insanity.

At the last annual meeting of the Medico-Psychological Association, held at the College of Physicians, London, in July, 1870, I brought forward a resolution which, after full discussion, was amended and agreed to, in these terms:— “That it is desirable to facilitate the early admission of all acute cases of pauper insanity into county (and borough) asylums, by providing for the proper care and treatment of chronic and harmless cases elsewhere.” The object of the resolution being to ensure for acute cases that prompt treatment which is so essential, and to prevent the overcrowding and overgrowth of asylums, by providing for the transfer of incurable and harmless cases to workhouses, or to lodgings, or to reside with relatives, under proper care, treatment, and supervision. In the absence of any such provision, the enlargement of asylums progresses—this will be shown by the returns of the increase of pauper insanity in England and Wales. Several institutions have attained such dimensions that the difficulty of proper management has become great. In such overgrown establishments the individuality of the curable patient is liable to become lost amongst the crowd of idiots and incurables. The delay in obtaining the forms required by the Lunacy Acts, prior to the admission of insane patients to pauper asylums, is a great hindrance to early treatment. As regards chronic cases, this delay is of little consequence, and from the comforts being greater in the asylum than in the workhouse infirmary, and it being to the interest of workhouse officials to send insane paupers to the asylum, the accumulation of chronic and incurable cases therein can easily be accounted for.